MEDICARE: CHARLOTTE 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	175T00000X	Peer Specialist

General Provider Information

NPI Number	:	1508550211
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLOTTE MACK

Provider Business Mailing Address
First Line	:	5801 BROADWAY EXT
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73118-7482
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5801 BROADWAY EXT
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73118-7482
Country	:	US
Telephone Number	:	405-424-7711
Fax Number	:

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

Provider Enumeration Date	:	06/06/2023
Last Update Date	:	06/06/2023

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Directions to “ CHARLOTTE MACK ” Practice Location

Language	Start Address	Practice Location

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