Provider Demographics
NPI:1578245593
Name:MASSINGILL, MACKENZIE (BCBA)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:MASSINGILL
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 1:3482 MCCLURE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-4164
Mailing Address - Country:US
Mailing Address - Phone:765-848-3547
Mailing Address - Fax:
Practice Address - Street 1:3482 MCCLURE AVE
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-4164
Practice Address - Country:US
Practice Address - Phone:765-848-3547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-23-67140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst