Provider Demographics
NPI:1417484973
Name:MALLEN, MCKENZIE RAE
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:RAE
Last Name:MALLEN
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 1:1175 CANE BAY BLVD
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-2396
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1175 CANE BAY BLVD
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29486-2396
Practice Address - Country:US
Practice Address - Phone:843-899-1957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-16
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC280059103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool