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NPI Code Detail

MEDICARE: MRS. SAMONE MACK

MEDICARE: MRS. SAMONE 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
1106S00000XBehavior Technician
2106S00000XBehavior TechnicianRBT-23-0527-562031

General Provider Information

NPI Number : 1609565944
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. SAMONE MACK
Provider Business Mailing Address
First Line : 1401 CHAMPIONS PINES LN
Second Line :
City : AUGUSTA
State : GA
Zip : 30909-4393
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 3830 WASHINGTON RD STE 2
Second Line :
City : MARTINEZ
State : GA
Zip : 30907-5065
Country : US
Telephone Number : 912-644-0212
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/03/2023
Last Update Date : 06/13/2023

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Directions to “ MRS. SAMONE MACK ” Practice Location

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