Provider Demographics
NPI:1134675275
Name:MACK, CYNTHIA NICOLE (DPT)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:NICOLE
Last Name:MACK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2724 SOQUEL AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-1433
Mailing Address - Country:US
Mailing Address - Phone:831-475-2565
Mailing Address - Fax:
Practice Address - Street 1:2724 SOQUEL AVE
Practice Address - Street 2:SUITE B
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-1433
Practice Address - Country:US
Practice Address - Phone:831-475-2565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-29
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA291934225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist