Provider Demographics
NPI:1841627403
Name:MACK-RAINEY, PAMELA
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:MACK-RAINEY
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 1:1533 WILLIAM LN
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-2434
Mailing Address - Country:US
Mailing Address - Phone:630-853-0139
Mailing Address - Fax:
Practice Address - Street 1:1533 WILLIAM LN
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2434
Practice Address - Country:US
Practice Address - Phone:630-853-0139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-27
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056003214225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist