Provider Demographics
NPI:1003217993
Name:MACKENZIE, KYLIE
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:
Last Name:MACKENZIE
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 1:2026 W BEACON AVE
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-4406
Mailing Address - Country:US
Mailing Address - Phone:657-276-7030
Mailing Address - Fax:
Practice Address - Street 1:22471 ASPAN ST STE 103
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-1644
Practice Address - Country:US
Practice Address - Phone:949-458-2715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-10
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health