Provider Demographics
NPI:1518397033
Name:BOON, MACKENZIE (PHD, LP)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:BOON
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:
Other - Last Name:BOHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2931 E BIDDLE ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21213-3939
Mailing Address - Country:US
Mailing Address - Phone:443-923-1872
Mailing Address - Fax:
Practice Address - Street 1:3230 W WILDWOOD DR
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68801-9609
Practice Address - Country:US
Practice Address - Phone:308-381-8851
Practice Address - Fax:308-381-8853
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-19
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1048103T00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor