Provider Demographics
NPI:1255677969
Name:MACK, KAILA NORMAN (PHD)
Entity type:Individual
Prefix:
First Name:KAILA
Middle Name:NORMAN
Last Name:MACK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 701 BOX 371
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96555-0004
Mailing Address - Country:US
Mailing Address - Phone:617-934-0219
Mailing Address - Fax:
Practice Address - Street 1:165 MIDDLESEX AVE STE 1118
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02145-1105
Practice Address - Country:US
Practice Address - Phone:617-934-0219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-27
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TB0200X
MA10244103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral