Provider Demographics
NPI:1003949116
Name:MACK, TONYA THERESA (LPTA)
Entity Type:Individual
Prefix:MS
First Name:TONYA
Middle Name:THERESA
Last Name:MACK
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2206 WOODWAY HILLS DR APT 1825
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-1608
Mailing Address - Country:US
Mailing Address - Phone:704-719-4765
Mailing Address - Fax:
Practice Address - Street 1:13180 DORMAN RD
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28134-9327
Practice Address - Country:US
Practice Address - Phone:704-542-0312
Practice Address - Fax:704-542-0313
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3514225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant