Provider Demographics
NPI:1275204562
Name:LANHAM, MACKENZIE RAE
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:RAE
Last Name:LANHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2631 171ST ST SE
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98012-6522
Mailing Address - Country:US
Mailing Address - Phone:208-310-1943
Mailing Address - Fax:
Practice Address - Street 1:18311 BOTHELL EVERETT HWY
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98012-5233
Practice Address - Country:US
Practice Address - Phone:206-437-5412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-26
Last Update Date:2021-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst