Provider Demographics
NPI:1982679403
Name:MACK, KATHLEEN A (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:A
Last Name:MACK
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:PO BOX 674
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:45140-0674
Mailing Address - Country:US
Mailing Address - Phone:513-771-8555
Mailing Address - Fax:513-771-8556
Practice Address - Street 1:8 TRIANGLE PARK DR
Practice Address - Street 2:SUITE 804
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45246-3404
Practice Address - Country:US
Practice Address - Phone:513-771-8555
Practice Address - Fax:513-771-8556
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-19
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3898103TC0700X, 103TH0100X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHR71519Medicare UPIN
OHCP05163Medicare ID - Type Unspecified