Provider Demographics
NPI:1154729713
Name:MACK, CHINNA LYNNELL (MSW, PCSW)
Entity type:Individual
Prefix:MISS
First Name:CHINNA
Middle Name:LYNNELL
Last Name:MACK
Suffix:
Gender:F
Credentials:MSW, PCSW
Other - Prefix:
Other - First Name:CHINNA
Other - Middle Name:LYNNLL
Other - Last Name:ROGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, PCSW
Mailing Address - Street 1:300 EAST 17TH ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-4608
Mailing Address - Country:US
Mailing Address - Phone:307-631-9931
Mailing Address - Fax:307-635-7706
Practice Address - Street 1:300 EAST 17TH ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-4608
Practice Address - Country:US
Practice Address - Phone:307-631-9931
Practice Address - Fax:307-635-7706
Is Sole Proprietor?:No
Enumeration Date:2014-12-15
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYCSW-238104100000X
WYPCSW-10361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker