Provider Demographics
NPI:1659456903
Name:MACK, JAMES L (PHD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:L
Last Name:MACK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29017 LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:BAY VILLAGE
Mailing Address - State:OH
Mailing Address - Zip Code:44140-1942
Mailing Address - Country:US
Mailing Address - Phone:440-899-1571
Mailing Address - Fax:
Practice Address - Street 1:29017 LINCOLN RD
Practice Address - Street 2:
Practice Address - City:BAY VILLAGE
Practice Address - State:OH
Practice Address - Zip Code:44140-1942
Practice Address - Country:US
Practice Address - Phone:440-899-1571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHP.1228103TC0700X
OH1228103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0254004Medicaid
OHCP12412Medicare PIN