Provider Demographics
NPI:1104371863
Name:MACKASON, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:MACKASON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3646 ROSEMONT AVE
Mailing Address - Street 2:
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-2326
Mailing Address - Country:US
Mailing Address - Phone:215-908-2387
Mailing Address - Fax:
Practice Address - Street 1:3646 ROSEMONT AVE
Practice Address - Street 2:
Practice Address - City:DREXEL HILL
Practice Address - State:PA
Practice Address - Zip Code:19026-2326
Practice Address - Country:US
Practice Address - Phone:215-908-2387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-23
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor