Provider Demographics
NPI:1841315488
Name:MACK, MAUREEN GRACE (OT)
Entity type:Individual
Prefix:MRS
First Name:MAUREEN
Middle Name:GRACE
Last Name:MACK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 STONEGATE DR
Mailing Address - Street 2:
Mailing Address - City:ROSELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:07068-1118
Mailing Address - Country:US
Mailing Address - Phone:973-403-8054
Mailing Address - Fax:
Practice Address - Street 1:190 PARK AVE
Practice Address - Street 2:
Practice Address - City:FLORHAM PARK
Practice Address - State:NJ
Practice Address - Zip Code:07932-1049
Practice Address - Country:US
Practice Address - Phone:973-292-6555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR10087800225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ46TR00187800OtherSTAE LICENSE