Provider Demographics
NPI:1487974366
Name:MACK, SARAH GORDON
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:GORDON
Last Name:MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 WILLOW BRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-5457
Mailing Address - Country:US
Mailing Address - Phone:919-403-3536
Mailing Address - Fax:
Practice Address - Street 1:45 WILLOW BRIDGE DR
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-5457
Practice Address - Country:US
Practice Address - Phone:919-403-3536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-02
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7239101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor