Provider Demographics
NPI:1548856701
Name:MACK, KEZIYAH NA'SHAY (AMFT)
Entity type:Individual
Prefix:
First Name:KEZIYAH
Middle Name:NA'SHAY
Last Name:MACK
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:KEZIYAH
Other - Middle Name:NA'SHAY
Other - Last Name:TANG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:591 CAMINO DE LA REINA STE 210
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3104
Mailing Address - Country:US
Mailing Address - Phone:619-206-5271
Mailing Address - Fax:619-591-5744
Practice Address - Street 1:591 CAMINO DE LA REINA STE 210
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3104
Practice Address - Country:US
Practice Address - Phone:619-206-5271
Practice Address - Fax:619-591-5744
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-11
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA139446106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA14137626488OtherEMPLOYER