Provider Demographics
NPI:1396388690
Name:AYERS, MACKENZIE LYN (LCSW)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:LYN
Last Name:AYERS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4410 BROOKFIELD CORPORATE DRIVE
Mailing Address - Street 2:#220941
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20153-8034
Mailing Address - Country:US
Mailing Address - Phone:571-390-8999
Mailing Address - Fax:
Practice Address - Street 1:25460 STALLION BRANCH TER
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20152-5809
Practice Address - Country:US
Practice Address - Phone:571-390-8999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-21
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040110721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical