Provider Demographics
NPI:1336292820
Name:MCKENZIE, NICHOLE JANELLE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLE
Middle Name:JANELLE
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 470064
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90047-9564
Mailing Address - Country:US
Mailing Address - Phone:213-219-8182
Mailing Address - Fax:
Practice Address - Street 1:9864 BALDWIN PL
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731-2202
Practice Address - Country:US
Practice Address - Phone:626-433-1311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY27389103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical