Provider Demographics
NPI:1407557754
Name:MACK, SYDNEY MAITLAND
Entity Type:Individual
Prefix:
First Name:SYDNEY
Middle Name:MAITLAND
Last Name:MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7771 ESTATE HILL ST APT 1331
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617-1970
Mailing Address - Country:US
Mailing Address - Phone:919-931-1028
Mailing Address - Fax:
Practice Address - Street 1:7771 ESTATE HILL ST APT 1331
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27617-1970
Practice Address - Country:US
Practice Address - Phone:919-931-1028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-14
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC000045752967106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician