Basic Information
| Provider Information | |||||||||
| NPI: | 1649707092 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MASHAK | ||||||||
| FirstName: | KRISTA | ||||||||
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| Credential: | LLMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 JESSOP RD | ||||||||
| Address2: | |||||||||
| City: | DANSVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488199615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178984231 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2700 BAKER ST FL 3 | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494442157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317371133 | ||||||||
| FaxNumber: | 2317370534 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2017 | ||||||||
| LastUpdateDate: | 01/12/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.