Provider Demographics
NPI:1477743193
Name:MACK, CARY NELSON (PHD)
Entity Type:Individual
Prefix:DR
First Name:CARY
Middle Name:NELSON
Last Name:MACK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9229 BLUEBONNET BLVD
Mailing Address - Street 2:STE B
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-2808
Mailing Address - Country:US
Mailing Address - Phone:225-766-7470
Mailing Address - Fax:225-766-7473
Practice Address - Street 1:10517 KENTSHIRE CT
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-2853
Practice Address - Country:US
Practice Address - Phone:225-769-8335
Practice Address - Fax:225-769-8396
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-30
Last Update Date:2014-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1035103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1345661Medicaid