Provider Demographics
NPI:1306213236
Name:GISH, MACKENZIE DEE (RADT-1)
Entity Type:Individual
Prefix:MS
First Name:MACKENZIE
Middle Name:DEE
Last Name:GISH
Suffix:
Gender:F
Credentials:RADT-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 CHERRY AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-3211
Mailing Address - Country:US
Mailing Address - Phone:916-532-0044
Mailing Address - Fax:
Practice Address - Street 1:7240 E SOUTHGATE DR
Practice Address - Street 2:SUITE G
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2627
Practice Address - Country:US
Practice Address - Phone:916-391-4293
Practice Address - Fax:916-391-4247
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator