1073892808 NPI number — DR. CHAD KILLPACK PSY.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073892808 NPI number — DR. CHAD KILLPACK PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KILLPACK
Provider First Name:
CHAD
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KILLPACK
Provider Other First Name:
CHAD
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PSY.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1073892808
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
48 MDG UNIT 5115
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APO
Provider Business Mailing Address State Name:
AE
Provider Business Mailing Address Postal Code:
09461
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
48 MDG UNIT 5115
Provider Second Line Business Practice Location Address:
EDIS
Provider Business Practice Location Address City Name:
APO
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
09461
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-226-3308
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/10/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  PY 60340649 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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