Provider Demographics
NPI:1639415078
Name:MARY LYNNE MACK PHD LLC
Entity Type:Organization
Organization Name:MARY LYNNE MACK PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:262-391-2551
Mailing Address - Street 1:N19W26738 MILKWEED LN UNIT A
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-5657
Mailing Address - Country:US
Mailing Address - Phone:262-391-2551
Mailing Address - Fax:
Practice Address - Street 1:20700 WATERTOWN RD STE 240
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-1800
Practice Address - Country:US
Practice Address - Phone:262-391-2551
Practice Address - Fax:262-264-1060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-12
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2598-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty