Provider Demographics
NPI:1417306879
Name:MACK, KATHLEEN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MACK
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 1:412 E NORTH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3720
Mailing Address - Country:US
Mailing Address - Phone:262-549-6123
Mailing Address - Fax:
Practice Address - Street 1:412 E NORTH ST
Practice Address - Street 2:SUITE A
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3720
Practice Address - Country:US
Practice Address - Phone:262-549-6123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2024-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist