=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619560992
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHLEEN ROSE MACK LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/17/2021
-----------------------------------------------------
Last Update Date | 02/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5555 N PORT WASHINGTON RD STE 200
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53217-4927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-789-1191
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2459 N 83RD ST
-----------------------------------------------------
City | WAUWATOSA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53213-1024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-507-4730
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 9613-123
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------