Provider Demographics
NPI:1528581188
Name:MACK, SHAMAKI LASHA (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SHAMAKI
Middle Name:LASHA
Last Name:MACK
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3037 DIAMOND DR
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08361-7516
Mailing Address - Country:US
Mailing Address - Phone:856-691-7016
Mailing Address - Fax:
Practice Address - Street 1:2250 HICKORY RD STE 240
Practice Address - Street 2:
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462-2225
Practice Address - Country:US
Practice Address - Phone:800-879-4471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-25
Last Update Date:2017-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00869000235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ41YS0086900OtherNEW JERSEY OFFICE OF THE ATTORNEY GENERAL DIVISION OF CONSUMER AFFAIRS