Provider Demographics
NPI:1093321945
Name:MACKENZIE, RENEE (LMT)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:MACKENZIE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:DENISE
Other - Last Name:JAPENGA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7575 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48091-2918
Mailing Address - Country:US
Mailing Address - Phone:850-217-8090
Mailing Address - Fax:
Practice Address - Street 1:7575 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091-2918
Practice Address - Country:US
Practice Address - Phone:850-217-8090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501011738225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist