Provider Demographics
NPI:1255677969
Name:MACK, KAILA NORMAN (PHD)
Entity Type:Individual
Prefix:
First Name:KAILA
Middle Name:NORMAN
Last Name:MACK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-2030
Mailing Address - Country:US
Mailing Address - Phone:617-724-4913
Mailing Address - Fax:
Practice Address - Street 1:151 MERRIMAC ST FL 3
Practice Address - Street 2:CHILD CBT PROGRAM AT MGH
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-4714
Practice Address - Country:US
Practice Address - Phone:617-724-4913
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-27
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10244103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral