Provider Demographics
NPI:1407508005
Name:WILSON, MACKENZIE MARIE-BROWN
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:MARIE-BROWN
Last Name:WILSON
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 1:96 DANFORTH ST APT 13
Mailing Address - Street 2:
Mailing Address - City:TAUNTON
Mailing Address - State:MA
Mailing Address - Zip Code:02780-2360
Mailing Address - Country:US
Mailing Address - Phone:508-315-2106
Mailing Address - Fax:
Practice Address - Street 1:96 DANFORTH ST APT 13
Practice Address - Street 2:
Practice Address - City:TAUNTON
Practice Address - State:MA
Practice Address - Zip Code:02780-2360
Practice Address - Country:US
Practice Address - Phone:508-315-2106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent