Provider Demographics
NPI:1821162488
Name:MACE, KARRIE MICHELLE (MA, EDS)
Entity Type:Individual
Prefix:MRS
First Name:KARRIE
Middle Name:MICHELLE
Last Name:MACE
Suffix:
Gender:F
Credentials:MA, EDS
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 120
Mailing Address - Street 2:
Mailing Address - City:CLAY
Mailing Address - State:WV
Mailing Address - Zip Code:25043-0120
Mailing Address - Country:US
Mailing Address - Phone:304-587-2713
Mailing Address - Fax:304-587-4181
Practice Address - Street 1:242 CHURCH STREET
Practice Address - Street 2:
Practice Address - City:CLAY
Practice Address - State:WV
Practice Address - Zip Code:25043-0120
Practice Address - Country:US
Practice Address - Phone:304-587-2713
Practice Address - Fax:304-587-4181
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810001065Medicaid