Provider Demographics
NPI:1508472689
Name:MAISON, MACKENZIE M (PT DPT)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:M
Last Name:MAISON
Suffix:
Gender:F
Credentials:PT DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5300 HICKORY PARK DR STE 110
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-2629
Mailing Address - Country:US
Mailing Address - Phone:804-756-8495
Mailing Address - Fax:
Practice Address - Street 1:13575 HEATHCOTE BLVD STE 250
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-6693
Practice Address - Country:US
Practice Address - Phone:571-261-9900
Practice Address - Fax:571-261-9908
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA2305213893225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist