Provider Demographics
NPI:1104241066
Name:MACK, AMY L (LICSW)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:MACK
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:VANDUSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:210 FAYETTE ST, SECOND FLOOR
Mailing Address - Street 2:
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104-1803
Mailing Address - Country:US
Mailing Address - Phone:315-897-5699
Mailing Address - Fax:315-302-9599
Practice Address - Street 1:210 FAYETTE ST, SECOND FLOOR
Practice Address - Street 2:
Practice Address - City:MANLIUS
Practice Address - State:NY
Practice Address - Zip Code:13104-1803
Practice Address - Country:US
Practice Address - Phone:315-897-5699
Practice Address - Fax:315-302-9599
Is Sole Proprietor?:No
Enumeration Date:2014-02-28
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH18431041C0700X
NY0907521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHRE2534Medicare PIN