Provider Demographics
NPI:1043604218
Name:MACK, BRITTANY JEAN (MSOT,OTR/L)
Entity type:Individual
Prefix:
First Name:BRITTANY
Middle Name:JEAN
Last Name:MACK
Suffix:
Gender:F
Credentials:MSOT,OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 WHITMAN RD
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-4813
Mailing Address - Country:US
Mailing Address - Phone:701-220-9310
Mailing Address - Fax:
Practice Address - Street 1:901 DIVISION ST NW
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-1641
Practice Address - Country:US
Practice Address - Phone:701-751-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-25
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1412225XP0200X
AZ6142225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist