Provider Demographics
NPI:1477149524
Name:MACK-PARKER, DIONTWANETTE DEEDEE (LLMSW)
Entity type:Individual
Prefix:MRS
First Name:DIONTWANETTE
Middle Name:DEEDEE
Last Name:MACK-PARKER
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 W LAKE LANSING RD STE C120
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-8483
Mailing Address - Country:US
Mailing Address - Phone:517-219-5761
Mailing Address - Fax:517-338-8022
Practice Address - Street 1:411 W LAKE LANSING RD STE C120
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-8483
Practice Address - Country:US
Practice Address - Phone:517-219-5761
Practice Address - Fax:517-338-8022
Is Sole Proprietor?:No
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011080241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical