Provider Demographics
NPI:1821623679
Name:MACK BROWN, KRISTIN (PSYD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:MACK BROWN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 CHESLEY DR STE 2
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-1760
Mailing Address - Country:US
Mailing Address - Phone:610-529-1875
Mailing Address - Fax:
Practice Address - Street 1:107 CHESLEY DR STE 2
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-1760
Practice Address - Country:US
Practice Address - Phone:610-529-1875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-11
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS019980103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1609423813Medicaid