Provider Demographics
NPI:1922691930
Name:MACK MENTAL HEALTH GROUP LLC
Entity Type:Organization
Organization Name:MACK MENTAL HEALTH GROUP LLC
Other - Org Name:MACK MENTAL HEALTH GROUP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:LPC/MHSP
Authorized Official - Phone:423-258-2161
Mailing Address - Street 1:1925 W ANDREW JOHNSON HWY UNIT 1
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37814-3757
Mailing Address - Country:US
Mailing Address - Phone:423-258-2161
Mailing Address - Fax:423-225-8432
Practice Address - Street 1:1925 W ANDREW JOHNSON HWY UNIT 1
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814-3757
Practice Address - Country:US
Practice Address - Phone:423-258-2161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-19
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)