Provider Demographics
NPI:1699896795
Name:MACK, KIM I (MFT)
Entity type:Individual
Prefix:MR
First Name:KIM
Middle Name:I
Last Name:MACK
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 KERN ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94805-1547
Mailing Address - Country:US
Mailing Address - Phone:510-215-9665
Mailing Address - Fax:
Practice Address - Street 1:712 KERN ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94805-1547
Practice Address - Country:US
Practice Address - Phone:510-215-9665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 22328106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist