Provider Demographics
NPI:1881251783
Name:MACK, THOMAS CRISWELL (PHD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:CRISWELL
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 1:2710 NORTH DODGE ST.
Mailing Address - Street 2:STE #1
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52245
Mailing Address - Country:US
Mailing Address - Phone:319-400-1311
Mailing Address - Fax:319-575-6025
Practice Address - Street 1:2710 NORTH DODGE ST.
Practice Address - Street 2:STE #1
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52245
Practice Address - Country:US
Practice Address - Phone:319-400-1311
Practice Address - Fax:319-575-6025
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-26
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA094424103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical