Provider Demographics
NPI:1578078432
Name:MACK, TRACY MARCEL
Entity Type:Individual
Prefix:MISS
First Name:TRACY
Middle Name:MARCEL
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 1:1206 PARKVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45044-5851
Mailing Address - Country:US
Mailing Address - Phone:513-915-2106
Mailing Address - Fax:
Practice Address - Street 1:1239 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-4103
Practice Address - Country:US
Practice Address - Phone:513-737-1247
Practice Address - Fax:513-737-3639
Is Sole Proprietor?:No
Enumeration Date:2017-12-13
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator