Provider Demographics
NPI:1720590516
Name:MACK, STACELYNNE (LMSW)
Entity Type:Individual
Prefix:
First Name:STACELYNNE
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:STACELYNNE
Other - Middle Name:
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 47505
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-5205
Mailing Address - Country:US
Mailing Address - Phone:248-506-4065
Mailing Address - Fax:
Practice Address - Street 1:30601 CREST FRST
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-1052
Practice Address - Country:US
Practice Address - Phone:248-506-4065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-02
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010825641041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool