Provider Demographics
NPI:1962032508
Name:MACK, ANGEL
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:
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 1:300 INTERNATIONAL PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5028
Mailing Address - Country:US
Mailing Address - Phone:407-915-7729
Mailing Address - Fax:407-588-6294
Practice Address - Street 1:2407 PLANTATION CENTER DR
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5418
Practice Address - Country:US
Practice Address - Phone:704-448-9819
Practice Address - Fax:704-270-8840
Is Sole Proprietor?:No
Enumeration Date:2020-01-23
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst