Provider Demographics
NPI:1568511517
Name:MACK, BEVERLY A (MS,CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:BEVERLY
Middle Name:A
Last Name:MACK
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 5TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:DEVILS LAKE
Mailing Address - State:ND
Mailing Address - Zip Code:58301-3649
Mailing Address - Country:US
Mailing Address - Phone:701-662-7690
Mailing Address - Fax:701-662-7684
Practice Address - Street 1:801 5TH AVE SE
Practice Address - Street 2:
Practice Address - City:DEVILS LAKE
Practice Address - State:ND
Practice Address - Zip Code:58301-3649
Practice Address - Country:US
Practice Address - Phone:701-662-7690
Practice Address - Fax:701-662-7684
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND429235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND59067Medicaid