Provider Demographics
NPI:1184680290
Name:MACKENZIE, PETER KENNETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:KENNETH
Last Name:MACKENZIE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 UNION ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:SPENCERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14559-1255
Mailing Address - Country:US
Mailing Address - Phone:585-349-2656
Mailing Address - Fax:585-352-5700
Practice Address - Street 1:85 UNION ST
Practice Address - Street 2:SUITE 206
Practice Address - City:SPENCERPORT
Practice Address - State:NY
Practice Address - Zip Code:14559-1255
Practice Address - Country:US
Practice Address - Phone:585-349-2656
Practice Address - Fax:585-352-5700
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012093-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical