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General NPI Number Information
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NPI Number | 1164567137
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Entity Type | Individual
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Provider Name | KATHLEEN SHACK M.S., LMFT
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Gender | Female
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Dates
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Enumeration Date | 02/20/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 290 CONSTITUTION BLVD SUITE D
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City | LAWRENCEVILLE
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State | GA
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Zip | 30045-5638
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Country | US
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Telephone | 678-220-0090
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Fax |
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Provider Business Mailing Address
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Address Line | 5825 MILLWICK DR
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City | ALPHARETTA
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State | GA
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Zip | 30005-6732
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Country | US
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Telephone | 678-770-2200
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 0000928
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License Number State | GA
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