Provider Demographics
NPI:1205120912
Name:MACK, KERI A
Entity type:Individual
Prefix:MRS
First Name:KERI
Middle Name:A
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 1:5419 BRIDLEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-3659
Mailing Address - Country:US
Mailing Address - Phone:716-523-0790
Mailing Address - Fax:
Practice Address - Street 1:5419 BRIDLEWOOD LN
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075-3659
Practice Address - Country:US
Practice Address - Phone:716-523-0790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-31
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY14405235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist