Provider Demographics
NPI:1528804838
Name:MACK, CONSUELO (SWT)
Entity type:Individual
Prefix:
First Name:CONSUELO
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:SWT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 LUDLOW ST
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45011-2903
Mailing Address - Country:US
Mailing Address - Phone:513-785-4899
Mailing Address - Fax:
Practice Address - Street 1:820 S MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45011-3216
Practice Address - Country:US
Practice Address - Phone:513-887-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-05
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2403535-TRNE104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker