Provider Demographics
NPI:1609866011
Name:MACK, JOAN M (PT)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:M
Last Name:MACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1574 UNION ST
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12309-6120
Mailing Address - Country:US
Mailing Address - Phone:518-374-2127
Mailing Address - Fax:518-374-2142
Practice Address - Street 1:1574 UNION ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12309-6120
Practice Address - Country:US
Practice Address - Phone:518-374-2127
Practice Address - Fax:518-374-2142
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-26
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0029001225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AA0727OtherMEDICARE GROUP NUMBER
NY0184495Medicaid
R55751Medicare UPIN
CC3554Medicare ID - Type Unspecified