Provider Demographics
NPI:1306414867
Name:MCCUTCHEN, MAKENZIE SUE (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:MAKENZIE
Middle Name:SUE
Last Name:MCCUTCHEN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:MS
Other - First Name:MAKENZIE
Other - Middle Name:S
Other - Last Name:SHARP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED
Mailing Address - Street 1:11049 RAUSCH CT
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:AR
Mailing Address - Zip Code:72730-2731
Mailing Address - Country:US
Mailing Address - Phone:479-427-9355
Mailing Address - Fax:
Practice Address - Street 1:11049 RAUSCH CT
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:AR
Practice Address - Zip Code:72730-2731
Practice Address - Country:US
Practice Address - Phone:479-427-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-11
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1-21-50435103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR814468304Medicaid