Provider Demographics
NPI:1770270944
Name:KAYEH, MACKIE JATELEE
Entity type:Individual
Prefix:
First Name:MACKIE
Middle Name:JATELEE
Last Name:KAYEH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6401 WILLOW LN APT 12
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55430-1908
Mailing Address - Country:US
Mailing Address - Phone:612-261-7743
Mailing Address - Fax:
Practice Address - Street 1:6401 WILLOW LN APT 12
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-1908
Practice Address - Country:US
Practice Address - Phone:612-261-7743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNNA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health