Provider Demographics
NPI:1902379498
Name:MACK, ALEXANDRA (CSW)
Entity Type:Individual
Prefix:MS
First Name:ALEXANDRA
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 S STATE ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-2724
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2200 S STATE ST STE 200
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-2724
Practice Address - Country:US
Practice Address - Phone:801-359-8862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10964194-3502104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker