Provider Demographics
NPI:1164942595
Name:SHRESTHA, MEKENZIE JOIRDAN (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:MEKENZIE
Middle Name:JOIRDAN
Last Name:SHRESTHA
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:MEKENZIE
Other - Middle Name:JOIRDAN
Other - Last Name:KEENPORTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTD, OTR/L
Mailing Address - Street 1:2150 S COUNTRY CLUB DR STE 20
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-6879
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2150 S COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-6809
Practice Address - Country:US
Practice Address - Phone:480-404-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2110225X00000X
AZOTH-007501225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist