MEDICARE: MACK OCCUPATIONAL THERAPY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XP0200X	Pediatric Occupational Therapist	3730	SC

General Provider Information

NPI Number	:	1063774107
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MACK OCCUPATIONAL THERAPY, LLC

Provider Business Mailing Address
First Line	:	1213 LLEWELLYN RD
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29464-3816
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1213 LLEWELLYN RD
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29464-3816
Country	:	US
Telephone Number	:	336-817-4278
Fax Number	:

Authorized Official
Title or Position	:	OCCUPATIONAL THERAPIST
Name	:	MRS. MARIA GONZALES MACK
Credential	:	MS OTR/L
Telephone Number	:	336-817-4278

Provider Enumeration Date	:	06/14/2012
Last Update Date	:	06/26/2012

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