Provider Demographics
NPI:1689165953
Name:MACK, TONYA R
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:R
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 1:1809 DE ARMAND AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45239-4880
Mailing Address - Country:US
Mailing Address - Phone:513-931-3551
Mailing Address - Fax:
Practice Address - Street 1:401 E MCMILLAN ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45206-1922
Practice Address - Country:US
Practice Address - Phone:513-931-3551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator