Provider Demographics
NPI:1215573324
Name:MCKENZIE, EILEEEN GRACE (LMFT)
Entity Type:Individual
Prefix:
First Name:EILEEEN
Middle Name:GRACE
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4850 PARADISE DR
Mailing Address - Street 2:
Mailing Address - City:TIBURON
Mailing Address - State:CA
Mailing Address - Zip Code:94920-1001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4850 PARADISE DR
Practice Address - Street 2:
Practice Address - City:TIBURON
Practice Address - State:CA
Practice Address - Zip Code:94920-1001
Practice Address - Country:US
Practice Address - Phone:415-505-5623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-24
Last Update Date:2019-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34655106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALMFT34655OtherCA DEPARTMENT OF CONSUMER AFFAIRS