Provider Demographics
NPI:1376198382
Name:REDD, MCKENZIE LEE (DPT)
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:LEE
Last Name:REDD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:754 N COLLEGE RD STE D
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5822
Mailing Address - Country:US
Mailing Address - Phone:208-734-5313
Mailing Address - Fax:
Practice Address - Street 1:754 N COLLEGE RD STE D
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5822
Practice Address - Country:US
Practice Address - Phone:208-734-5313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-6361225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist