MEDICARE: MS. SANDRA M MACK MSW,CSW

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2172359000	OTHER	PA	PERSONAL CHOICE2

General Provider Information

NPI Number	:	1962571307
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SANDRA M MACK MSW,CSW

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

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	07/08/2007

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