Provider Demographics
NPI:1053527846
Name:MACK, CAROL MARIE (DPT)
Entity type:Individual
Prefix:DR
First Name:CAROL
Middle Name:MARIE
Last Name:MACK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3835 CLARIDGE OVAL
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-4739
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3835 CLARIDGE OVAL
Practice Address - Street 2:
Practice Address - City:UNIVERSITY HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44118-4739
Practice Address - Country:US
Practice Address - Phone:440-759-4828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT.011577405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional