Provider Demographics
NPI:1902356710
Name:MACK, MICHAEL ANTHONY (RADT-1)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:MACK
Suffix:
Gender:M
Credentials:RADT-1
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 3218
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93385-3218
Mailing Address - Country:US
Mailing Address - Phone:661-325-1817
Mailing Address - Fax:661-325-3929
Practice Address - Street 1:600 BERNARD ST
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93305-3020
Practice Address - Country:US
Practice Address - Phone:661-325-1817
Practice Address - Fax:661-325-9329
Is Sole Proprietor?:No
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARADT-1 1234200716101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)