Provider Demographics
NPI:1043831100
Name:MACKENZIE, KELLY MARIE (PHD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:MACKENZIE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:832 BRUNSWICK AVE
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08638-3847
Mailing Address - Country:US
Mailing Address - Phone:609-815-7400
Mailing Address - Fax:
Practice Address - Street 1:832 BRUNSWICK AVE
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08638-3847
Practice Address - Country:US
Practice Address - Phone:609-815-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-29
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA390200000X103TC0700X
NJ35SI00780000103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical