Provider Demographics
NPI:1588021281
Name:MACK, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
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 1:331 S WATER ST
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:WI
Mailing Address - Zip Code:54656-1726
Mailing Address - Country:US
Mailing Address - Phone:608-366-6239
Mailing Address - Fax:
Practice Address - Street 1:331 S WATER ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:WI
Practice Address - Zip Code:54656-1726
Practice Address - Country:US
Practice Address - Phone:608-366-6239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-26
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2314225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant