Provider Demographics
NPI:1760405070
Name:SACK, NANCY L (PHD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:L
Last Name:SACK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6701 WINTON BLOUNT BLVD UNIT 242972
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36124-5139
Mailing Address - Country:US
Mailing Address - Phone:334-590-8492
Mailing Address - Fax:334-270-9757
Practice Address - Street 1:259 OLD JASMINE HILL RD
Practice Address - Street 2:
Practice Address - City:WETUMPKA
Practice Address - State:AL
Practice Address - Zip Code:36093-3421
Practice Address - Country:US
Practice Address - Phone:334-590-8492
Practice Address - Fax:334-270-9757
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2021-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL691103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL74243OtherBCBS
680014097OtherMCR RAILROAD
R62294Medicare UPIN
000074243Medicare ID - Type Unspecified