MEDICARE: ANITA JEAN MACK

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	104100000X	Social Worker

General Provider Information

NPI Number	:	1578225678
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANITA JEAN MACK

Provider Business Mailing Address
First Line	:	12595 WINDY POINTE LOOP APT 108
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32824-5365
Country	:	US
Telephone Number	:	317-827-4725
Fax Number	:

Provider Business Practice Location Address
First Line	:	4954 E 56TH ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-5773
Country	:	US
Telephone Number	:	317-500-4266
Fax Number	:

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

Provider Enumeration Date	:	10/06/2021
Last Update Date	:	10/20/2022

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Directions to “ ANITA JEAN MACK ” Practice Location

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