Provider Demographics
NPI:1295603397
Name:MACKENZIE, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:MACKENZIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3367 CASCADES BLVD APT 128
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75709-5448
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3367 CASCADES BLVD APT 128
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75709-5448
Practice Address - Country:US
Practice Address - Phone:903-780-5313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-29
Last Update Date:2025-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO22440101YP2500X
TX86686101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional