Provider Demographics
NPI:1467519082
Name:MCKENZIE, TIFFANY JACQUELINE (MA, LPA)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:JACQUELINE
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:MA, LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2013 WATERTON LN
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-9003
Mailing Address - Country:US
Mailing Address - Phone:919-303-4941
Mailing Address - Fax:
Practice Address - Street 1:8390 SIX FORKS RD
Practice Address - Street 2:SUITE #201
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-3060
Practice Address - Country:US
Practice Address - Phone:919-782-8730
Practice Address - Fax:919-782-8731
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2424103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107128Medicaid