Provider Demographics
NPI:1487209003
Name:MACK, GERACI (LBSW, MHA, CHAPLAIN)
Entity Type:Individual
Prefix:
First Name:GERACI
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:LBSW, MHA, CHAPLAIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 W UPSHUR AVE
Mailing Address - Street 2:
Mailing Address - City:GLADEWATER
Mailing Address - State:TX
Mailing Address - Zip Code:75647-2124
Mailing Address - Country:US
Mailing Address - Phone:903-918-8152
Mailing Address - Fax:
Practice Address - Street 1:408 W UPSHUR AVE
Practice Address - Street 2:
Practice Address - City:GLADEWATER
Practice Address - State:TX
Practice Address - Zip Code:75647-2124
Practice Address - Country:US
Practice Address - Phone:903-918-8152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-09
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101YA0400X, 101YM0800X, 101YP1600X, 251S00000X, 251K00000X
TX26197104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251K00000XAgenciesPublic Health or Welfare
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health