Provider Demographics
NPI:1265095491
Name:MACK, ROY HAMILTON JR (LGPC)
Entity type:Individual
Prefix:MR
First Name:ROY
Middle Name:HAMILTON
Last Name:MACK
Suffix:JR
Gender:M
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:653 POSSUM TROT WAY
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:MD
Mailing Address - Zip Code:21001-2658
Mailing Address - Country:US
Mailing Address - Phone:443-224-5443
Mailing Address - Fax:
Practice Address - Street 1:4317 HARFORD RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21214-3118
Practice Address - Country:US
Practice Address - Phone:443-224-5443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-14
Last Update Date:2019-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP9275101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional