Provider Demographics
NPI:1275011181
Name:MACK, CYNTHIA JENELL
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:JENELL
Last Name:MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 PIERREPONT ST APT 9B
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-2840
Mailing Address - Country:US
Mailing Address - Phone:347-355-3768
Mailing Address - Fax:
Practice Address - Street 1:195 BAY 19TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-4761
Practice Address - Country:US
Practice Address - Phone:718-253-1366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY751414696OtherDRIVERS LICENSE