Provider Demographics
NPI:1932648060
Name:MACK, ALEXANDRA
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
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 1:3001 PARK CENTER DR APT 308
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22302-1440
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:901 N WASHINGTON ST STE 703
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-1535
Practice Address - Country:US
Practice Address - Phone:703-224-8983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-22
Last Update Date:2022-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLG50083785104100000X
MD28030104100000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No104100000XBehavioral Health & Social Service ProvidersSocial Worker