Provider Demographics
NPI:1477908812
Name:MCKENZIE, SAMANTHA JANE (BA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JANE
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 N OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-2831
Mailing Address - Country:US
Mailing Address - Phone:920-770-4088
Mailing Address - Fax:651-705-0026
Practice Address - Street 1:123 N OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-2831
Practice Address - Country:US
Practice Address - Phone:920-770-4088
Practice Address - Fax:651-705-0026
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-03
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5304101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional