Basic Information
| Provider Information | |||||||||
| NPI: | 1851493621 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACKTA | ||||||||
| FirstName: | NINA | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | |||||||||
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| Credential: | LICSW | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 40 WATCH HILL WAY | ||||||||
| Address2: | |||||||||
| City: | WAKEFIELD | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028797692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4013311350 | ||||||||
| FaxNumber: | 4012773366 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 WATCH HILL WAY | ||||||||
| Address2: | |||||||||
| City: | WAKEFIELD | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028797692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017923664 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2006 | ||||||||
| LastUpdateDate: | 04/11/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | ISW01136 | RI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 413619 | 01 | BLUE CHIP | OTHER | 31708-9 | 01 | BLUE CROSS BLUE SHIELD | OTHER |