Provider Demographics
NPI:1255796132
Name:MACK, RENEE ELLEN
Entity type:Individual
Prefix:MS
First Name:RENEE
Middle Name:ELLEN
Last Name:MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 PELHAM PKWY. SOUTH
Mailing Address - Street 2:JACOBI M.C, 4 WEST 6
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461
Mailing Address - Country:US
Mailing Address - Phone:718-918-6123
Mailing Address - Fax:718-918-7222
Practice Address - Street 1:1400 PELHAM PKWY. SOUTH
Practice Address - Street 2:4 WEST 6
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461
Practice Address - Country:US
Practice Address - Phone:718-918-6123
Practice Address - Fax:718-918-7222
Is Sole Proprietor?:No
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY72035396104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker