Provider Demographics
NPI:1780879353
Name:MACK, KATIE LINN (MA)
Entity type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:LINN
Last Name:MACK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:LINN
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:510 PRINCIPAL DRUMMOND WAY SE
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20175-4100
Mailing Address - Country:US
Mailing Address - Phone:571-252-1920
Mailing Address - Fax:
Practice Address - Street 1:510 PRINCIPAL DRUMMOND WAY SE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20175-4100
Practice Address - Country:US
Practice Address - Phone:571-252-1920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-07
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL008630235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist