MEDICARE: MRS. MARIA MACK OTR/L

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	225XP0200X	Pediatric Occupational Therapist	3730	SC

General Provider Information

NPI Number	:	1114237823
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARIA MACK OTR/L

Provider Business Mailing Address
First Line	:	1213 LLEWELLYN RD
Second Line	:
City	:	MT PLEASANT
State	:	SC
Zip	:	29464-3816
Country	:	US
Telephone Number	:	336-817-4278
Fax Number	:

Provider Business Practice Location Address
First Line	:	1213 LLEWELLYN RD
Second Line	:
City	:	MT PLEASANT
State	:	SC
Zip	:	29464-3816
Country	:	US
Telephone Number	:	336-817-4278
Fax Number	:

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

Provider Enumeration Date	:	10/15/2010
Last Update Date	:	06/26/2012

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