Provider Demographics
NPI:1356627608
Name:MACKUS, SARA C (MA)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:C
Last Name:MACKUS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 S MATTIS AVE
Mailing Address - Street 2:APT. V
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-3639
Mailing Address - Country:US
Mailing Address - Phone:217-359-5726
Mailing Address - Fax:
Practice Address - Street 1:311 W WHITE ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-4805
Practice Address - Country:US
Practice Address - Phone:217-359-5276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical