Provider Demographics
NPI:1275297913
Name:STENSTROM, MACKENZIE (LMBP)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:STENSTROM
Suffix:
Gender:F
Credentials:LMBP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 PARSLEY DR
Mailing Address - Street 2:
Mailing Address - City:HUBERT
Mailing Address - State:NC
Mailing Address - Zip Code:28539-4223
Mailing Address - Country:US
Mailing Address - Phone:218-310-0514
Mailing Address - Fax:
Practice Address - Street 1:411 WESTERN BLVD STE B
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6822
Practice Address - Country:US
Practice Address - Phone:910-581-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19857225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist