Provider Demographics
NPI:1225727670
Name:MACKIE, GEORGINEA L (INTERN MSW STUDENT)
Entity Type:Individual
Prefix:
First Name:GEORGINEA
Middle Name:L
Last Name:MACKIE
Suffix:
Gender:F
Credentials:INTERN MSW STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13585 SAN PABLO AVENUE 1ST FLOOR
Mailing Address - Street 2:
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13585 SAN PABLO AVENUE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806
Practice Address - Country:US
Practice Address - Phone:510-942-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-02
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program