Provider Demographics
NPI:1457658767
Name:HENRY-MACK, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:HENRY-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 1:6210 DOLLARWAY RD
Mailing Address - Street 2:STE 4
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71602-3733
Mailing Address - Country:US
Mailing Address - Phone:870-247-3588
Mailing Address - Fax:870-247-2072
Practice Address - Street 1:6210 DOLLARWAY RD
Practice Address - Street 2:STE 4
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71602-3733
Practice Address - Country:US
Practice Address - Phone:870-247-3588
Practice Address - Fax:870-247-2072
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-23
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA1101001101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor