MEDICARE: SANDRA M. MACK

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	1041C0700X	Clinical Social Worker	CW013656	PA

General Provider Information

NPI Number	:	1497801575
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANDRA M. MACK

Provider Business Mailing Address
First Line	:	2053 BRANDYWINE ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19130-3204
Country	:	US
Telephone Number	:	610-470-3215
Fax Number	:	215-568-1410

Provider Business Practice Location Address
First Line	:	1 PRESIDENTIAL BLVD
Second Line	:	SUITE 204
City	:	BALA CYNWYD
State	:	PA
Zip	:	19004-1017
Country	:	US
Telephone Number	:	610-470-3215
Fax Number	:	215-568-1410

Authorized Official
Title or Position	:	OWNER
Name	:	MS. SANDRA M. MACK
Credential	:	MSW, CSW
Telephone Number	:	610-470-3215

Provider Enumeration Date	:	01/25/2007
Last Update Date	:	08/22/2020

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