Basic Information
| Provider Information | |||||||||
| NPI: | 1588761530 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACK | ||||||||
| FirstName: | DESRA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4300 SAPPHIRE CT STE 110 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278349079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2528307540 | ||||||||
| FaxNumber: | 2524130932 | ||||||||
| Practice Location | |||||||||
| Address1: | 1141 N ROAD ST | ||||||||
| Address2: | SUITE L | ||||||||
| City: | ELIZABETH CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 279093354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2523350803 | ||||||||
| FaxNumber: | 2523311796 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 03/01/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 5415 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 6103306 | 05 | NC | MEDICAID |