Provider Demographics
NPI:1528226727
Name:MACK, RAMONA (MA, CCC- SLP)
Entity Type:Individual
Prefix:
First Name:RAMONA
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:MA, CCC- SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 PEPPERGRASS CT
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:SC
Mailing Address - Zip Code:29045-8294
Mailing Address - Country:US
Mailing Address - Phone:803-553-0088
Mailing Address - Fax:
Practice Address - Street 1:63 PEPPERGRASS CT
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:SC
Practice Address - Zip Code:29045-8294
Practice Address - Country:US
Practice Address - Phone:803-553-0088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-26
Last Update Date:2008-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3020235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0296Medicaid