Provider Demographics
NPI:1104663723
Name:ZACK, MACIE KATHRYN (MS, OTRL)
Entity type:Individual
Prefix:
First Name:MACIE
Middle Name:KATHRYN
Last Name:ZACK
Suffix:
Gender:F
Credentials:MS, OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 GRAND AVE APT 642
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-4898
Mailing Address - Country:US
Mailing Address - Phone:616-430-1651
Mailing Address - Fax:
Practice Address - Street 1:1101 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4004
Practice Address - Country:US
Practice Address - Phone:360-899-4905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201013663225X00000X
WA61555390225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist