MEDICARE: MACIE KATHRYN ZACK MS, OTRL

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	225X00000X	Occupational Therapist	5201013663	MI
2	225X00000X	Occupational Therapist	61555390	WA

General Provider Information

NPI Number	:	1104663723
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MACIE KATHRYN ZACK MS, OTRL

Provider Business Mailing Address
First Line	:	2900 GRAND AVE APT 642
Second Line	:
City	:	EVERETT
State	:	WA
Zip	:	98201-4898
Country	:	US
Telephone Number	:	616-430-1651
Fax Number	:

Provider Business Practice Location Address
First Line	:	1101 E DIVISION ST
Second Line	:
City	:	MOUNT VERNON
State	:	WA
Zip	:	98274-4004
Country	:	US
Telephone Number	:	360-899-4905
Fax Number	:

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

Provider Enumeration Date	:	07/11/2024
Last Update Date	:	07/11/2024

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