Provider Demographics
NPI:1558696807
Name:MACK, CHRISTINE A (OT)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:A
Last Name:MACK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:
Other - Last Name:BENDER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:86 THOMAS JOHNSON CT
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4348
Mailing Address - Country:US
Mailing Address - Phone:301-694-8311
Mailing Address - Fax:301-694-3537
Practice Address - Street 1:184 THOMAS JOHNSON DR STE 104
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4476
Practice Address - Country:US
Practice Address - Phone:301-694-8311
Practice Address - Fax:301-694-3537
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06137225X00000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC231008ZCM2Medicare PIN
MD231020ZDEGMedicare PIN