Provider Demographics
NPI:1427404664
Name:MACK, EDWINA (MSW)
Entity Type:Individual
Prefix:
First Name:EDWINA
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 KILLIAN LAKES DR
Mailing Address - Street 2:APT 4303
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-8804
Mailing Address - Country:US
Mailing Address - Phone:843-325-5466
Mailing Address - Fax:
Practice Address - Street 1:1800 KILLIAN LAKES DR
Practice Address - Street 2:APT 4303
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-8804
Practice Address - Country:US
Practice Address - Phone:843-325-5466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-06
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health