Provider Demographics
NPI:1114166337
Name:TAYLOR, MACKENZIE L (LICSW)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:L
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 HUDSON ST STE 5
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2949
Mailing Address - Country:US
Mailing Address - Phone:503-926-9413
Mailing Address - Fax:360-967-8030
Practice Address - Street 1:1655 HUDSON ST STE 5
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2949
Practice Address - Country:US
Practice Address - Phone:503-926-9413
Practice Address - Fax:360-967-8030
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-11
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YA0400X, 1041C0700X
WALW604950011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)