Provider Demographics
NPI:1083267298
Name:LOPEZ, MACKENZIE TAYLOR (PTA)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:TAYLOR
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:TAYLOR
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1111 E WESTVIEW CT STE A
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99218-1376
Mailing Address - Country:US
Mailing Address - Phone:509-465-5170
Mailing Address - Fax:509-465-1748
Practice Address - Street 1:1855 1ST ST
Practice Address - Street 2:
Practice Address - City:CHENEY
Practice Address - State:WA
Practice Address - Zip Code:99004-1966
Practice Address - Country:US
Practice Address - Phone:509-559-5038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-17
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160941708225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant