Provider Demographics
NPI:1700811015
Name:MACK, MARY LYNNE (PHD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LYNNE
Last Name:MACK
Suffix:
Gender:F
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:N19W26738 MILKWEED LN UNIT A
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-5657
Mailing Address - Country:US
Mailing Address - Phone:262-391-2551
Mailing Address - Fax:262-264-1060
Practice Address - Street 1:20700 WATERTOWN RD STE 240
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-1800
Practice Address - Country:US
Practice Address - Phone:262-391-2551
Practice Address - Fax:262-264-1060
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2598-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40916300Medicaid
WI40916300Medicaid