Provider Demographics
NPI:1265266647
Name:MACK, SHAVONE
Entity type:Individual
Prefix:
First Name:SHAVONE
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 1:7258 S YATES BLVD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649-2558
Mailing Address - Country:US
Mailing Address - Phone:773-712-5089
Mailing Address - Fax:
Practice Address - Street 1:3320 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN PARK
Practice Address - State:IL
Practice Address - Zip Code:60131-1514
Practice Address - Country:US
Practice Address - Phone:773-377-5492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist