Provider Demographics
NPI:1073214763
Name:MACK, NYSHEKA ETRENA
Entity Type:Individual
Prefix:
First Name:NYSHEKA
Middle Name:ETRENA
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 1:1212 TALBERT ST SE APT 201
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-5211
Mailing Address - Country:US
Mailing Address - Phone:443-969-5426
Mailing Address - Fax:
Practice Address - Street 1:1212 TALBERT ST SE APT 201
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-5211
Practice Address - Country:US
Practice Address - Phone:443-969-5426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-10
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC106S00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician