Provider Demographics
NPI:1073848974
Name:MACK, WENDY JOAN (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:WENDY
Middle Name:JOAN
Last Name:MACK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 1ST AVE SE
Mailing Address - Street 2:
Mailing Address - City:AITKIN
Mailing Address - State:MN
Mailing Address - Zip Code:56431-1711
Mailing Address - Country:US
Mailing Address - Phone:218-839-1792
Mailing Address - Fax:
Practice Address - Street 1:213 1ST AVE SE
Practice Address - Street 2:
Practice Address - City:AITKIN
Practice Address - State:MN
Practice Address - Zip Code:56431-1711
Practice Address - Country:US
Practice Address - Phone:218-839-1792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-09
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101530225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation