Provider Demographics
NPI:1760416903
Name:MACK, KEVIN JOSEPH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JOSEPH
Last Name:MACK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:COVELO
Mailing Address - State:CA
Mailing Address - Zip Code:95428-0247
Mailing Address - Country:US
Mailing Address - Phone:707-983-6648
Mailing Address - Fax:707-983-6649
Practice Address - Street 1:23000 HENDERSON ROAD
Practice Address - Street 2:
Practice Address - City:COVELO
Practice Address - State:CA
Practice Address - Zip Code:95428-0247
Practice Address - Country:US
Practice Address - Phone:707-983-6648
Practice Address - Fax:707-983-6649
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 12983103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical