Provider Demographics
NPI:1770167546
Name:WINGREEN, MACK KENNETH
Entity type:Individual
Prefix:
First Name:MACK
Middle Name:KENNETH
Last Name:WINGREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6617 HIGH BEACH CT E
Mailing Address - Street 2:
Mailing Address - City:NEW MARKET
Mailing Address - State:MD
Mailing Address - Zip Code:21774-6852
Mailing Address - Country:US
Mailing Address - Phone:410-530-3361
Mailing Address - Fax:
Practice Address - Street 1:7407 WILLOW RD
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-2500
Practice Address - Country:US
Practice Address - Phone:301-644-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-07
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA4884225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant