Provider Demographics
NPI:1710568910
Name:MACON, MARY GRACE (LMSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:GRACE
Last Name:MACON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12921 CANTRELL RD STE 105
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-1798
Mailing Address - Country:US
Mailing Address - Phone:501-891-5492
Mailing Address - Fax:
Practice Address - Street 1:12921 CANTRELL RD STE 105
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72223-1798
Practice Address - Country:US
Practice Address - Phone:501-891-5492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR10428-M104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker