Provider Demographics
NPI:1588648216
Name:MACYS, MARY JURATE (PHD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JURATE
Last Name:MACYS
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 1:8139 NEW LAGRANGE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-4682
Mailing Address - Country:US
Mailing Address - Phone:502-423-9509
Mailing Address - Fax:502-423-9501
Practice Address - Street 1:8139 NEW LAGRANGE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-4682
Practice Address - Country:US
Practice Address - Phone:502-423-9509
Practice Address - Fax:502-423-9501
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0983103TC0700X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYCP00113Medicare ID - Type Unspecified