Provider Demographics
NPI:1073506481
Name:MACK, JOANNE (OT)
Entity Type:Individual
Prefix:MRS
First Name:JOANNE
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-3126
Mailing Address - Country:US
Mailing Address - Phone:860-647-1493
Mailing Address - Fax:860-643-6709
Practice Address - Street 1:155 MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-3126
Practice Address - Country:US
Practice Address - Phone:860-647-1493
Practice Address - Fax:860-643-6709
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000491225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist