Provider Demographics
NPI:1477072841
Name:MACKE, GREG WILLIAM (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:WILLIAM
Last Name:MACKE
Suffix:
Gender:M
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 CARNEGIE AVE STE 1C
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-5504
Mailing Address - Country:US
Mailing Address - Phone:800-273-4292
Mailing Address - Fax:949-253-4627
Practice Address - Street 1:1901 CARNEGIE AVENUE
Practice Address - Street 2:SUITE 1-C
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705
Practice Address - Country:US
Practice Address - Phone:800-273-4292
Practice Address - Fax:949-253-4627
Is Sole Proprietor?:No
Enumeration Date:2017-09-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-17-25900103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst