Provider Demographics
NPI:1912341082
Name:MACK, TERI (OTR/L)
Entity type:Individual
Prefix:
First Name:TERI
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 W 86TH ST
Mailing Address - Street 2:#1B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-4028
Mailing Address - Country:US
Mailing Address - Phone:917-951-4259
Mailing Address - Fax:
Practice Address - Street 1:144 W 86TH ST
Practice Address - Street 2:#1B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-4028
Practice Address - Country:US
Practice Address - Phone:917-951-4259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-19
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007551-1225X00000X
CT3404225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist