Provider Demographics
NPI:1861893117
Name:MACK, MICHELE (LMT, CPMT)
Entity type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:LMT, CPMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3850 POWDER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-1292
Mailing Address - Country:US
Mailing Address - Phone:614-886-0290
Mailing Address - Fax:
Practice Address - Street 1:2179 STRINGTOWN RD
Practice Address - Street 2:LOFT 11
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-2989
Practice Address - Country:US
Practice Address - Phone:614-886-0290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-05
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.02129080225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist