Provider Demographics
NPI:1093243206
Name:MCKENZIE, KATHLEEN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MCKENZIE
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 1:6372 MECHANICSVILLE TPKE STE 105
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23111-4705
Mailing Address - Country:US
Mailing Address - Phone:804-559-4625
Mailing Address - Fax:804-559-4627
Practice Address - Street 1:6372 MECHANICSVILLE TPKE STE 105
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23111-4705
Practice Address - Country:US
Practice Address - Phone:804-559-4625
Practice Address - Fax:804-559-4627
Is Sole Proprietor?:No
Enumeration Date:2017-06-01
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2101002152237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2101002152OtherSTATE LICENSE