Provider Demographics
NPI:1003215740
Name:MCKENZIE, KEITH (CADC)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:MCKENZIE
Suffix:
Gender:M
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 W BROADWAY STE 905
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-2133
Mailing Address - Country:US
Mailing Address - Phone:502-587-9737
Mailing Address - Fax:
Practice Address - Street 1:332 W BROADWAY STE 905
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-2133
Practice Address - Country:US
Practice Address - Phone:502-587-9737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-19
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0656101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100323580Medicaid