Provider Demographics
NPI:1689942625
Name:MARRIAGE & FAMILY THERAPY ASSOCIATES
Entity Type:Organization
Organization Name:MARRIAGE & FAMILY THERAPY ASSOCIATES
Other - Org Name:RICHARD N. MACK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:NEWELL
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:MDIV, LMFT
Authorized Official - Phone:315-282-7076
Mailing Address - Street 1:2 SOUTH ST STE 210
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-6174
Mailing Address - Country:US
Mailing Address - Phone:315-282-7076
Mailing Address - Fax:
Practice Address - Street 1:2 SOUTH ST STE 210
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-6174
Practice Address - Country:US
Practice Address - Phone:315-282-7076
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000906106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty