Provider Demographics
NPI:1003327610
Name:GARRISON, MACKENZIE BRYANT (LBSW)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:BRYANT
Last Name:GARRISON
Suffix:
Gender:M
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 F ST # B
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-1930
Mailing Address - Country:US
Mailing Address - Phone:208-799-4440
Mailing Address - Fax:
Practice Address - Street 1:1118 F ST # B
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-1930
Practice Address - Country:US
Practice Address - Phone:208-799-4440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-23
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID36722104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker