Provider Demographics
NPI:1306280870
Name:MACK, ARDIANNE VALORIE (COTA/L)
Entity type:Individual
Prefix:MS
First Name:ARDIANNE
Middle Name:VALORIE
Last Name:MACK
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 HAWKINS LANDING RD
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:SC
Mailing Address - Zip Code:29541-3841
Mailing Address - Country:US
Mailing Address - Phone:843-624-3146
Mailing Address - Fax:
Practice Address - Street 1:405 WAKE ROBIN CT
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505-3189
Practice Address - Country:US
Practice Address - Phone:843-678-9813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-26
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2524224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant