Provider Demographics
NPI:1396852315
Name:NACK, MADELINE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MADELINE
Middle Name:
Last Name:NACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 LESLIE LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-6809
Mailing Address - Country:US
Mailing Address - Phone:631-271-4902
Mailing Address - Fax:631-271-5076
Practice Address - Street 1:10 LESLIE LN
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-6809
Practice Address - Country:US
Practice Address - Phone:631-271-4902
Practice Address - Fax:631-271-5076
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYLCSWR0156711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN26581Medicare ID - Type Unspecified