Provider Demographics
NPI:1578318903
Name:MACK, EMILY ROSE (MSW)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:ROSE
Last Name:MACK
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7744 E CTY RD V
Mailing Address - Street 2:
Mailing Address - City:SOUTH RANGE
Mailing Address - State:WI
Mailing Address - Zip Code:54874
Mailing Address - Country:US
Mailing Address - Phone:715-919-0748
Mailing Address - Fax:
Practice Address - Street 1:2207 E 5TH ST
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-3708
Practice Address - Country:US
Practice Address - Phone:715-919-0748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-19
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11691-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical