Provider Demographics
NPI:1649845454
Name:MACK, ALEXIS LISA (DPT)
Entity type:Individual
Prefix:MISS
First Name:ALEXIS
Middle Name:LISA
Last Name:MACK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:ALEXIS
Other - Middle Name:LISA
Other - Last Name:PETERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:6965 GOLDFINCH CT
Mailing Address - Street 2:
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-1376
Mailing Address - Country:US
Mailing Address - Phone:716-548-2930
Mailing Address - Fax:
Practice Address - Street 1:2540 SHERIDAN DR
Practice Address - Street 2:
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14150-9410
Practice Address - Country:US
Practice Address - Phone:716-862-0567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-24
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist