Provider Demographics
NPI:1508090655
Name:HACK, KATHRYN RUSSELL (MA, MFT)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:RUSSELL
Last Name:HACK
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15720 VENTURA BLVD
Mailing Address - Street 2:SUITE # 201
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2914
Mailing Address - Country:US
Mailing Address - Phone:818-235-3733
Mailing Address - Fax:
Practice Address - Street 1:15720 VENTURA BLVD
Practice Address - Street 2:SUITE # 201
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2914
Practice Address - Country:US
Practice Address - Phone:818-235-3733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-04
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 16321106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist