Provider Demographics
NPI:1467217810
Name:FERGUSON, MACKENZIE RAE
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:RAE
Last Name:FERGUSON
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 1:7513 MANSLICK RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40214-4141
Mailing Address - Country:US
Mailing Address - Phone:502-602-3223
Mailing Address - Fax:
Practice Address - Street 1:1230 LIBERTY BANK LN STE 230
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5756
Practice Address - Country:US
Practice Address - Phone:855-444-5664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-15
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician