Provider Demographics
NPI:1578158903
Name:MACALLISTER, MCKENZIE D (MS OTR/L CPAM)
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:D
Last Name:MACALLISTER
Suffix:
Gender:F
Credentials:MS OTR/L CPAM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 TIMBER WALK
Mailing Address - Street 2:
Mailing Address - City:DAWSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30534-5337
Mailing Address - Country:US
Mailing Address - Phone:770-377-5200
Mailing Address - Fax:
Practice Address - Street 1:1715 FRIENDSHIP CIR
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30028-6917
Practice Address - Country:US
Practice Address - Phone:770-240-0163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT005764225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGA005764OtherGEORGIA SECRETARY OF STATE OCCUPATIONAL THERAPY LICENSING BOARD
315531OtherNATIONAL BOARD FOR CERTIFICATION IN OCCUPATIONAL THERAPY