Provider Demographics
NPI:1376261263
Name:RESTUCCI, MACKENZIE COLLEN
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:COLLEN
Last Name:RESTUCCI
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 1:1320 LOUISIANA AVE STE A
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-4116
Mailing Address - Country:US
Mailing Address - Phone:407-593-0122
Mailing Address - Fax:
Practice Address - Street 1:1320 LOUISIANA AVE STE A
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-4116
Practice Address - Country:US
Practice Address - Phone:407-593-0122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-17
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty