Provider Demographics
NPI:1881465037
Name:MACK, CYNTHIA C (LMT)
Entity type:Individual
Prefix:MISS
First Name:CYNTHIA
Middle Name:C
Last Name:MACK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4437 W WEST END AVE BSMT
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60624-2147
Mailing Address - Country:US
Mailing Address - Phone:312-933-7235
Mailing Address - Fax:
Practice Address - Street 1:4437 W WEST END AVE BSMT
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60624-2147
Practice Address - Country:US
Practice Address - Phone:312-933-7235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227002354225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist