Provider Demographics
NPI:1033845581
Name:BAYLESS, MAKENZIE LEE (LAC)
Entity Type:Individual
Prefix:
First Name:MAKENZIE
Middle Name:LEE
Last Name:BAYLESS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:281 MELROSE ST
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-2515
Mailing Address - Country:US
Mailing Address - Phone:609-947-0244
Mailing Address - Fax:
Practice Address - Street 1:15 W PROSPECT ST STE 200
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-2161
Practice Address - Country:US
Practice Address - Phone:732-254-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00587000101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ37AC00587000OtherBOARD OF MARRIAGE AND FAMILY THERAPY