Provider Demographics
NPI:1568199354
Name:BURT, MACKENZIE R (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:MACKENZIE
Middle Name:R
Last Name:BURT
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 CASS AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507-1118
Mailing Address - Country:US
Mailing Address - Phone:231-335-0936
Mailing Address - Fax:
Practice Address - Street 1:100 60TH ST SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49548-6804
Practice Address - Country:US
Practice Address - Phone:616-538-4120
Practice Address - Fax:616-538-8770
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011149161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical