Healthcare Provider Details

I. General information

NPI: 1093671182
Provider Name (Legal Business Name): KIMBERLY YVETTE MACK MAADC I
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/01/2026
Last Update Date: 01/01/2026
Certification Date: 01/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9733 SAINT CHARLES ROCK RD
SAINT LOUIS MO
63114-2625
US

IV. Provider business mailing address

5512 MABLE AVE APT B3
SAINT LOUIS MO
63140-1414
US

V. Phone/Fax

Practice location:
  • Phone: 314-423-7030
  • Fax: 314-423-9511
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: