Provider Demographics
NPI:1225210917
Name:MACK, JOANN L (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JOANN
Middle Name:L
Last Name:MACK
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3571 8TH ST
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-7157
Mailing Address - Country:US
Mailing Address - Phone:309-236-3614
Mailing Address - Fax:
Practice Address - Street 1:2925 28TH AVENUE A
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6924
Practice Address - Country:US
Practice Address - Phone:309-762-7974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-04
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.004703235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist