Provider Demographics
NPI:1073174827
Name:MACON, KIA (MSW)
Entity Type:Individual
Prefix:
First Name:KIA
Middle Name:
Last Name:MACON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 N CLINTON AVE BLDG 1
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08609-1011
Mailing Address - Country:US
Mailing Address - Phone:609-394-9398
Mailing Address - Fax:
Practice Address - Street 1:39 N CLINTON AVE BLDG 1
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08609-1011
Practice Address - Country:US
Practice Address - Phone:609-394-9398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator