Provider Demographics
NPI:1558739680
Name:MACKOVJAK, KATIE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:MACKOVJAK
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 1:145 S ENTERPRISE ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-2913
Mailing Address - Country:US
Mailing Address - Phone:440-655-5671
Mailing Address - Fax:
Practice Address - Street 1:145 S ENTERPRISE ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-2913
Practice Address - Country:US
Practice Address - Phone:440-655-5671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-06
Last Update Date:2015-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer