MEDICARE: MR. OTIS MACK II LMSW

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	072983-1	NY

General Provider Information

NPI Number	:	1083827760
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. OTIS MACK II LMSW

Provider Business Mailing Address
First Line	:	25924 147TH AVE
Second Line	:	PVT. H.
City	:	ROSEDALE
State	:	NY
Zip	:	11422-3321
Country	:	US
Telephone Number	:	718-525-2923
Fax Number	:

Provider Business Practice Location Address
First Line	:	606 WINTHROP ST
Second Line	:	'G' BUILDING
City	:	BROOKLYN
State	:	NY
Zip	:	11203-1709
Country	:	US
Telephone Number	:	718-245-2348
Fax Number	:	718-245-2416

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

Provider Enumeration Date	:	05/08/2007
Last Update Date	:	07/08/2007

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