Provider Demographics
NPI:1356832091
Name:GOFF, MCKENZIE
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:
Last Name:GOFF
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 1:416 S LEWIS ST
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-3517
Mailing Address - Country:US
Mailing Address - Phone:405-564-4248
Mailing Address - Fax:
Practice Address - Street 1:920 S MURPHY ST APT 2205
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-1588
Practice Address - Country:US
Practice Address - Phone:405-249-8195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKN083386971OtherLICENSE