Provider Demographics
NPI:1669654943
Name:MACKLIN, TITERRIELL
Entity type:Individual
Prefix:
First Name:TITERRIELL
Middle Name:
Last Name:MACKLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7528 AVALON SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40228-2588
Mailing Address - Country:US
Mailing Address - Phone:502-386-8638
Mailing Address - Fax:
Practice Address - Street 1:7528 AVALON SPRINGS DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40228-2588
Practice Address - Country:US
Practice Address - Phone:502-386-8638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-29
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY283528101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)