Provider Demographics
NPI:1992447551
Name:MACKIE, KATELYNNE
Entity type:Individual
Prefix:
First Name:KATELYNNE
Middle Name:
Last Name:MACKIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 EAST ST
Mailing Address - Street 2:
Mailing Address - City:WHITINSVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:01588-1923
Mailing Address - Country:US
Mailing Address - Phone:508-234-1332
Mailing Address - Fax:
Practice Address - Street 1:130 EAST ST
Practice Address - Street 2:
Practice Address - City:WHITINSVILLE
Practice Address - State:MA
Practice Address - Zip Code:01588-1923
Practice Address - Country:US
Practice Address - Phone:508-234-1332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-12
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist