Healthcare Provider Details

I. General information

NPI: 1376840017
Provider Name (Legal Business Name): ANYA L MACK LISW-S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2011
Last Update Date: 05/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 NAVE RD SE
MASSILLON OH
44646-9604
US

IV. Provider business mailing address

625 CLEVELAND AVE NW
CANTON OH
44702-1805
US

V. Phone/Fax

Practice location:
  • Phone: 330-837-9411
  • Fax: 330-837-4603
Mailing address:
  • Phone: 304-550-3743
  • Fax: 330-453-6716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI1500756SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: