Provider Demographics
NPI:1780228650
Name:MACK, DANIELLE ANDREE (LMSW-CC)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:ANDREE
Last Name:MACK
Suffix:
Gender:F
Credentials:LMSW-CC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7044
Mailing Address - Street 2:
Mailing Address - City:CAPE PORPOISE
Mailing Address - State:ME
Mailing Address - Zip Code:04014-7044
Mailing Address - Country:US
Mailing Address - Phone:910-742-3771
Mailing Address - Fax:
Practice Address - Street 1:100 GANNETT DR
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-5900
Practice Address - Country:US
Practice Address - Phone:207-854-1030
Practice Address - Fax:207-899-4623
Is Sole Proprietor?:No
Enumeration Date:2019-11-04
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC182071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEUNKNOWNOtherMAINECARE