Provider Demographics
NPI:1417564238
Name:MACK, RACHEL MICHELE
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:MICHELE
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 1:714 PARKVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:STAUNTON
Mailing Address - State:VA
Mailing Address - Zip Code:24401-2018
Mailing Address - Country:US
Mailing Address - Phone:678-412-5220
Mailing Address - Fax:
Practice Address - Street 1:7648 MCGAHEYSVILLE RD
Practice Address - Street 2:
Practice Address - City:PENN LAIRD
Practice Address - State:VA
Practice Address - Zip Code:22846-9779
Practice Address - Country:US
Practice Address - Phone:540-289-3401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2204000482235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2204000482OtherBOARD OF AUDIOLOGY AND SPEECH LANGUAGE PATHOLOGY