Provider Demographics
NPI:1689071136
Name:MACK, SHANEQUA (LMSW)
Entity Type:Individual
Prefix:MS
First Name:SHANEQUA
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 CEDAR AVE APT 10E
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-5536
Mailing Address - Country:US
Mailing Address - Phone:646-261-3798
Mailing Address - Fax:
Practice Address - Street 1:2121 CEDAR AVE APT 10E
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-5536
Practice Address - Country:US
Practice Address - Phone:646-261-3798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-28
Last Update Date:2014-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY084464104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker