Provider Demographics
NPI:1932543188
Name:MACK-MARTIN, BEVERLY (CADAC IV, LCAC)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:MACK-MARTIN
Suffix:
Gender:F
Credentials:CADAC IV, LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3171 N MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-4784
Mailing Address - Country:US
Mailing Address - Phone:317-941-5010
Mailing Address - Fax:317-931-5140
Practice Address - Street 1:3171 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46208-4784
Practice Address - Country:US
Practice Address - Phone:317-941-5010
Practice Address - Fax:317-931-5140
Is Sole Proprietor?:No
Enumeration Date:2013-04-18
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87000590A101YA0400X
INCIV-1536101YA0400X
INICAADC-1536101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)