Provider Demographics
NPI:1114312741
Name:MACADANGDANG, KATHRYN ELIZABETH (LPC)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ELIZABETH
Last Name:MACADANGDANG
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:ELIZABETH
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:504 W 29TH ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85713-3353
Mailing Address - Country:US
Mailing Address - Phone:520-884-9920
Mailing Address - Fax:
Practice Address - Street 1:504 W 29TH ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85713
Practice Address - Country:US
Practice Address - Phone:520-884-9920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-31
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC 15366101Y00000X
AZLPC13948101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ346993Medicaid