Provider Demographics
NPI:1376918797
Name:MACK, COLLEEN (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 JFK DR
Mailing Address - Street 2:SUITE 132
Mailing Address - City:ATLANTIS
Mailing Address - State:FL
Mailing Address - Zip Code:33462-1141
Mailing Address - Country:US
Mailing Address - Phone:215-303-3699
Mailing Address - Fax:
Practice Address - Street 1:130 JFK DR
Practice Address - Street 2:SUITE 132
Practice Address - City:ATLANTIS
Practice Address - State:FL
Practice Address - Zip Code:33462-1141
Practice Address - Country:US
Practice Address - Phone:561-841-6250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-10
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X
PARN324249L163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health