Provider Demographics
NPI:1629578935
Name:MACK, LASHAUNDA
Entity Type:Individual
Prefix:
First Name:LASHAUNDA
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14311 SW 258TH LN
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-6771
Mailing Address - Country:US
Mailing Address - Phone:804-514-2386
Mailing Address - Fax:
Practice Address - Street 1:14311 SW 258TH LN
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032
Practice Address - Country:US
Practice Address - Phone:804-514-2386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-14
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst