Provider Demographics
NPI:1144930439
Name:KIRKWOOD, MACY MIKAILA
Entity type:Individual
Prefix:
First Name:MACY
Middle Name:MIKAILA
Last Name:KIRKWOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 S GRAND AVE UNIT 2
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-9103
Mailing Address - Country:US
Mailing Address - Phone:661-607-8428
Mailing Address - Fax:
Practice Address - Street 1:1411 W 190TH ST
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-4324
Practice Address - Country:US
Practice Address - Phone:310-719-3908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-29
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst