Provider Demographics
NPI:1083827760
Name:MACK, OTIS II (LMSW)
Entity Type:Individual
Prefix:MR
First Name:OTIS
Middle Name:
Last Name:MACK
Suffix:II
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25924 147TH AVE
Mailing Address - Street 2:PVT. H.
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-3321
Mailing Address - Country:US
Mailing Address - Phone:718-525-2923
Mailing Address - Fax:
Practice Address - Street 1:606 WINTHROP ST
Practice Address - Street 2:'G' BUILDING
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-1709
Practice Address - Country:US
Practice Address - Phone:718-245-2348
Practice Address - Fax:718-245-2416
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY072983-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker