Provider Demographics
NPI:1487075792
Name:MACK, AMY MARIE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:MACK
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:MARIE
Other - Last Name:KLUCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:31618 EVENINGSIDE
Mailing Address - Street 2:
Mailing Address - City:FRASER
Mailing Address - State:MI
Mailing Address - Zip Code:48026-3320
Mailing Address - Country:US
Mailing Address - Phone:586-285-1346
Mailing Address - Fax:
Practice Address - Street 1:44738 MORLEY DR
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48036-1357
Practice Address - Country:US
Practice Address - Phone:586-421-4072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-05
Last Update Date:2014-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101001758235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist