Provider Demographics
NPI:1508536467
Name:RILEY, MACKENZIE (BCBA)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:RILEY
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2520 SOUTH BLVD APT 241
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-6644
Mailing Address - Country:US
Mailing Address - Phone:678-956-0655
Mailing Address - Fax:
Practice Address - Street 1:716 EAST BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5114
Practice Address - Country:US
Practice Address - Phone:919-375-0475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-24-70977103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst