Provider Demographics
NPI:1720239437
Name:MACKO, LORI ANN (PTA)
Entity Type:Individual
Prefix:MISS
First Name:LORI
Middle Name:ANN
Last Name:MACKO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:396 SCHWABE ST
Mailing Address - Street 2:
Mailing Address - City:FREELAND
Mailing Address - State:PA
Mailing Address - Zip Code:18224-1218
Mailing Address - Country:US
Mailing Address - Phone:570-636-2012
Mailing Address - Fax:
Practice Address - Street 1:1548 SANS SOUCI PKWY
Practice Address - Street 2:
Practice Address - City:HANOVER TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18706-6028
Practice Address - Country:US
Practice Address - Phone:570-825-8725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-01
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE007045225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant