Provider Demographics
NPI:1992044135
Name:MACKILLOP, MARCIA KIPP (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARCIA
Middle Name:KIPP
Last Name:MACKILLOP
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 HAWTHORNE AVE
Mailing Address - Street 2:
Mailing Address - City:EWING
Mailing Address - State:NJ
Mailing Address - Zip Code:08638-2823
Mailing Address - Country:US
Mailing Address - Phone:609-672-6668
Mailing Address - Fax:
Practice Address - Street 1:4 PRINCESS RD STE 206
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-2322
Practice Address - Country:US
Practice Address - Phone:609-482-3701
Practice Address - Fax:609-482-3702
Is Sole Proprietor?:No
Enumeration Date:2013-02-07
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0203241041C0700X
NJ44SC055214001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA097115OtherDDAP
PA144400OtherDOH-MH
NJ2000480OtherDMHAS-SUD
NJ896321004OtherDMHAS-MH