Basic Information
| Provider Information | |||||||||
| NPI: | 1225252638 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACKU | ||||||||
| FirstName: | KRISTY | ||||||||
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| Credential: | LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 645 S ROGERS ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474032353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123391691 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1530 N COMMERCE W DR | ||||||||
| Address2: | |||||||||
| City: | GREENSBURG | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472403205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8126637057 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2007 | ||||||||
| LastUpdateDate: | 11/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 39004096A | IN | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.