Provider Demographics
NPI:1629297346
Name:MACK, LISA K (LSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:K
Last Name:MACK
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1022 HAMBURG TPKE
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-3209
Mailing Address - Country:US
Mailing Address - Phone:973-694-1234
Mailing Address - Fax:973-633-0992
Practice Address - Street 1:1022 HAMBURG TPKE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-3209
Practice Address - Country:US
Practice Address - Phone:973-694-1234
Practice Address - Fax:973-633-0992
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL053433001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical