Provider Demographics
NPI:1013438415
Name:MACK, STEFANIE MARIE
Entity type:Individual
Prefix:MS
First Name:STEFANIE
Middle Name:MARIE
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 1:4998 13TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-3816
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:540 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT ANGEL
Practice Address - State:OR
Practice Address - Zip Code:97362-9540
Practice Address - Country:US
Practice Address - Phone:503-949-6963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-06
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator