Provider Demographics
NPI:1508524364
Name:KECK, MACKENZIE ELIZABETH (OTR)
Entity Type:Individual
Prefix:MRS
First Name:MACKENZIE
Middle Name:ELIZABETH
Last Name:KECK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MISS
Other - First Name:MACKENZIE
Other - Middle Name:ELIZABETH
Other - Last Name:SISKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:PO BOX 903
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-0903
Mailing Address - Country:US
Mailing Address - Phone:423-894-4774
Mailing Address - Fax:423-894-4775
Practice Address - Street 1:4071 S ACCESS RD STE 108
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37406-1200
Practice Address - Country:US
Practice Address - Phone:423-894-4774
Practice Address - Fax:423-894-4775
Is Sole Proprietor?:No
Enumeration Date:2021-11-29
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225XP0019X
TN7133225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ073272Medicaid