Provider Demographics
NPI:1790679306
Name:MACK, KATHRYN MORAN (LAMFT)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MORAN
Last Name:MACK
Suffix:
Gender:F
Credentials:LAMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11660 ROUND LAKE BLVD NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2638
Mailing Address - Country:US
Mailing Address - Phone:763-767-7883
Mailing Address - Fax:
Practice Address - Street 1:11660 ROUND LAKE BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2638
Practice Address - Country:US
Practice Address - Phone:763-767-7883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-06
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3770106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist