Provider Demographics
NPI:1275030611
Name:WALLIS, MACKENZIE (LCSW)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:WALLIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7540 SW 59TH CT APT 8
Mailing Address - Street 2:
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-5147
Mailing Address - Country:US
Mailing Address - Phone:719-321-2790
Mailing Address - Fax:
Practice Address - Street 1:2355 SALZEDO ST STE 311
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-5061
Practice Address - Country:US
Practice Address - Phone:719-321-2790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW135081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical