Provider Demographics
NPI:1508472952
Name:MACK, JUSTIN OTTIS (QMHS, CDCA)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:OTTIS
Last Name:MACK
Suffix:
Gender:M
Credentials:QMHS, CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1370 WEST BLVD APT 8
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44102-1737
Mailing Address - Country:US
Mailing Address - Phone:716-446-3944
Mailing Address - Fax:
Practice Address - Street 1:12395 MCCRACKEN RD # UP
Practice Address - Street 2:
Practice Address - City:GARFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44125-2967
Practice Address - Country:US
Practice Address - Phone:216-587-6727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-21
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH176595101YA0400X
OHUH804004171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)