Provider Demographics
NPI:1932484714
Name:MACK, MADLYN REGINA
Entity Type:Individual
Prefix:MS
First Name:MADLYN
Middle Name:REGINA
Last Name:MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 W CHEYENNE AVE STE 30
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-7817
Mailing Address - Country:US
Mailing Address - Phone:702-487-5665
Mailing Address - Fax:
Practice Address - Street 1:720 W CHEYENNE AVE STE 30
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-7817
Practice Address - Country:US
Practice Address - Phone:702-487-5665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1401577626Medicaid