MEDICARE: EBONY MACK LCSW

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	1041C0700X	Clinical Social Worker	0904018396	VA

General Provider Information

NPI Number	:	1538959895
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EBONY MACK LCSW

Provider Business Mailing Address
First Line	:	3317 WOODROW AVE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23222-2720
Country	:	US
Telephone Number	:	646-963-1103
Fax Number	:

Provider Business Practice Location Address
First Line	:	3317 WOODROW AVE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23222-2720
Country	:	US
Telephone Number	:	646-963-1103
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/09/2025
Last Update Date	:	05/09/2025

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