Provider Demographics
NPI:1578225678
Name:MACK, ANITA JEAN
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:JEAN
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 1:12595 WINDY POINTE LOOP APT 108
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32824-5365
Mailing Address - Country:US
Mailing Address - Phone:317-827-4725
Mailing Address - Fax:
Practice Address - Street 1:4954 E 56TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-5773
Practice Address - Country:US
Practice Address - Phone:317-500-4266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-06
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty