Provider Demographics
NPI:1447801311
Name:BALDERAZ, MACKENZIE
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:BALDERAZ
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 1:1422 HOOVER DR
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:TX
Mailing Address - Zip Code:77536-5157
Mailing Address - Country:US
Mailing Address - Phone:281-733-0785
Mailing Address - Fax:
Practice Address - Street 1:1422 HOOVER DR
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:TX
Practice Address - Zip Code:77536-5157
Practice Address - Country:US
Practice Address - Phone:281-733-0785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX202321106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist