Active NPI
Desmond Mack
- Professional Counselor
- Southfield, MI
National Provider Identifier
1053058800
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Professional Counselor
- License
- 640108797
- Practice address
- 20411 W 12 Mile Rd Ste 104
Southfield, MI 48076-6404 - Phone
- (248) 617-7545
- NPI assigned
- May 13, 2022
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Professional Counselor | 101YP2500X | 640108797 | Primary |
Addresses
Primary practice location
20411 W 12 Mile Rd Ste 104
Southfield, MI 48076-6404
Mailing address
20411 W 12 Mile Rd Ste 104
Southfield, MI 48076-6404
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1652400000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1652400000000",
"number": "1053058800",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "20411 W 12 MILE RD STE 104",
"city": "SOUTHFIELD",
"state": "MI",
"postal_code": "480766404"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "20411 W 12 MILE RD STE 104",
"city": "SOUTHFIELD",
"state": "MI",
"postal_code": "480766404",
"telephone_number": "248-617-7545"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MACK",
"first_name": "DESMOND",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2022-05-13",
"last_updated": "2022-05-13",
"certification_date": "2022-05-13",
"status": "A"
},
"taxonomies": [
{
"code": "101YP2500X",
"taxonomy_group": "",
"desc": "Counselor, Professional",
"state": null,
"license": "640108797",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Southfield, MI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 13, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.