Provider Demographics
NPI:1346742913
Name:DEMINICO, MACKENZIE A
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:A
Last Name:DEMINICO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 ELM ST STE 7
Mailing Address - Street 2:
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01089-1540
Mailing Address - Country:US
Mailing Address - Phone:413-734-0300
Mailing Address - Fax:
Practice Address - Street 1:1111 ELM ST STE 7
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-1540
Practice Address - Country:US
Practice Address - Phone:413-734-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-28
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026265EMedicaid