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NPI Code Detail

MEDICARE: MS. KIMBERLY YVETTE MACK MAADC I

MEDICARE: MS. KIMBERLY YVETTE MACK MAADC I
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YA0400XAddiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number : 1093671182
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. KIMBERLY YVETTE MACK MAADC I
Provider Business Mailing Address
First Line : 5512 MABLE AVE APT B3
Second Line :
City : SAINT LOUIS
State : MO
Zip : 63140-1414
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 9733 SAINT CHARLES ROCK RD
Second Line :
City : SAINT LOUIS
State : MO
Zip : 63114-2625
Country : US
Telephone Number : 314-423-7030
Fax Number : 314-423-9511
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/01/2026
Last Update Date : 01/01/2026

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