Provider Demographics
NPI:1003483165
Name:MACK, VACERA M (COTA)
Entity Type:Individual
Prefix:
First Name:VACERA
Middle Name:M
Last Name:MACK
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36048 WOODINGHAM ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-1680
Mailing Address - Country:US
Mailing Address - Phone:586-237-7569
Mailing Address - Fax:
Practice Address - Street 1:36048 WOODINGHAM ST
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035-1680
Practice Address - Country:US
Practice Address - Phone:586-237-7569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202007393224ZF0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224ZF0002XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantFeeding, Eating & SwallowingGroup - Single Specialty