Provider Demographics
NPI:1033817747
Name:MACK, KSENIA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KSENIA
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1995 SELKIRK CT
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:IL
Mailing Address - Zip Code:60010-5504
Mailing Address - Country:US
Mailing Address - Phone:847-420-6249
Mailing Address - Fax:
Practice Address - Street 1:4657 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-2024
Practice Address - Country:US
Practice Address - Phone:773-989-6472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-21
Last Update Date:2023-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X, 2251X0800X
IL070.027296225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic