Provider Demographics
NPI:1396222519
Name:HARDIE, MACKENZIE (PT)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:HARDIE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:
Other - Last Name:MEARS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:500 CROSS STREET
Mailing Address - Street 2:
Mailing Address - City:BIG STONE CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57216
Mailing Address - Country:US
Mailing Address - Phone:605-541-1140
Mailing Address - Fax:
Practice Address - Street 1:8 5TH ST SE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-3713
Practice Address - Country:US
Practice Address - Phone:605-753-5400
Practice Address - Fax:605-753-6208
Is Sole Proprietor?:No
Enumeration Date:2018-07-20
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD2063225100000X
MN11200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist