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General NPI Number Information
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NPI Number | 1497801575
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Entity Type | Organization
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Legal Business Name | SANDRA M. MACK
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Dates
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Enumeration Date | 01/25/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1 PRESIDENTIAL BLVD SUITE 204
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City | BALA CYNWYD
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State | PA
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Zip | 19004-1017
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Country | US
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Telephone | 610-470-3215
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Fax | 215-568-1410
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Provider Business Mailing Address
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Address Line | 2053 BRANDYWINE ST
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City | PHILADELPHIA
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State | PA
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Zip | 19130-3204
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Country | US
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Telephone | 610-470-3215
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Fax | 215-568-1410
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Authorized Official
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Title or Position | OWNER
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Name | MS. SANDRA M. MACK
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Credential | MSW, CSW
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Telephone | 610-470-3215
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | CW013656
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License Number State | PA
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