Provider Demographics
NPI:1114935160
Name:MACKENZIE, BETH (MSW)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:MACKENZIE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2444 WILSHIRE BLVD
Mailing Address - Street 2:SUITE #400
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-5808
Mailing Address - Country:US
Mailing Address - Phone:310-998-8841
Mailing Address - Fax:
Practice Address - Street 1:2444 WILSHIRE BLVD
Practice Address - Street 2:SUITE #400
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5808
Practice Address - Country:US
Practice Address - Phone:310-998-8841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS140231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASW14023Medicare UPIN