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NPI Code Detail

MEDICARE: KRISTINA WOODWARD MACKIE MSW, LCSW

MEDICARE: KRISTINA WOODWARD MACKIE MSW, LCSW
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
11041C0700XClinical Social WorkerASW 22155CA
21041C0700XClinical Social WorkerLCSW #27104CA

General Provider Information

NPI Number : 1780870998
Entity Type Code : Individual
Provider Name (Legal Business Name) : KRISTINA WOODWARD MACKIE MSW, LCSW
Provider Business Mailing Address
First Line : 9500 ETIWANDA AVE
Second Line :
City : RANCHO CUCAMONGA
State : CA
Zip : 91739-9662
Country : US
Telephone Number : 909-463-5234
Fax Number :
Provider Business Practice Location Address
First Line : 5330 SAN BERNARDINO ST
Second Line :
City : MONTCLAIR
State : CA
Zip : 91763-2952
Country : US
Telephone Number : 909-399-3751
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/20/2007
Last Update Date : 12/06/2021

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