Provider Demographics
NPI:1669523106
Name:MACK, GREGORY IRVING (PHD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:IRVING
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:PO BOX 533
Mailing Address - Street 2:
Mailing Address - City:SHRUB OAK
Mailing Address - State:NY
Mailing Address - Zip Code:10588-0533
Mailing Address - Country:US
Mailing Address - Phone:845-282-3367
Mailing Address - Fax:914-743-1613
Practice Address - Street 1:345 KEAR ST
Practice Address - Street 2:SUITE 202
Practice Address - City:YORKTOWN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:10598-4425
Practice Address - Country:US
Practice Address - Phone:845-282-3367
Practice Address - Fax:914-743-1613
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2017-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016597103TC0700X, 103TF0200X, 103TB0200X, 103TF0000X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03577942Medicaid