Healthcare Provider Details

I. General information

NPI: 1033615240
Provider Name (Legal Business Name): KIMBERLY NIYOGI MACC, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2018
Last Update Date: 04/15/2024
Certification Date: 04/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 MARKET ST
BANGOR PA
18013-1901
US

IV. Provider business mailing address

914 PAXINOSA AVE
EASTON PA
18042-1309
US

V. Phone/Fax

Practice location:
  • Phone: 610-588-9109
  • Fax:
Mailing address:
  • Phone: 610-217-9030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC014528
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: