Provider Demographics
NPI:1417000902
Name:MACK, JULIE (PHD)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1816 DUCHESS DR
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-2034
Mailing Address - Country:US
Mailing Address - Phone:970-227-2740
Mailing Address - Fax:
Practice Address - Street 1:1816 DUCHESS DR
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-2034
Practice Address - Country:US
Practice Address - Phone:970-227-2740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2326103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
634946Medicare ID - Type Unspecified