Provider Demographics
NPI:1295163665
Name:MACEK, KIMBERLY (PHD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:
Last Name:MACEK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 NORTHERN BLVD STE 404
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-3022
Mailing Address - Country:US
Mailing Address - Phone:917-485-5991
Mailing Address - Fax:
Practice Address - Street 1:1129 NORTHERN BLVD STE 404
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3022
Practice Address - Country:US
Practice Address - Phone:917-485-5991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-23
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TM1800X, 283Q00000X
NY022035103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No283Q00000XHospitalsPsychiatric Hospital