MEDICARE: AUDREY MACKINAC GARCIA 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	104100000X	Social Worker	0009924098	CO
2	1041C0700X	Clinical Social Worker	CSW.09931013	CO
3	1041C0700X	Clinical Social Worker	6843	SD

General Provider Information

NPI Number	:	1043041775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUDREY MACKINAC GARCIA LCSW

Provider Business Mailing Address
First Line	:	PO BOX 110429
Second Line	:
City	:	AURORA
State	:	CO
Zip	:	80042-0429
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2405 E 19TH ST
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57103-2358
Country	:	US
Telephone Number	:	612-965-3947
Fax Number	:

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

Provider Enumeration Date	:	08/13/2024
Last Update Date	:	08/19/2025

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