Provider Demographics
NPI:1962571307
Name:MACK, SANDRA M (MSW,CSW)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:M
Last Name:MACK
Suffix:
Gender:F
Credentials:MSW,CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2053 BRANDYWINE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-3204
Mailing Address - Country:US
Mailing Address - Phone:215-568-1410
Mailing Address - Fax:215-568-1410
Practice Address - Street 1:1 PRESIDENTIAL BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1017
Practice Address - Country:US
Practice Address - Phone:610-470-3215
Practice Address - Fax:215-568-1410
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0136561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2172359000OtherPERSONAL CHOICE2
PA2172359000OtherPERSONAL CHOICE2