Provider Demographics
NPI:1578283362
Name:HARRELL, MACKENZIE LESLIE (RD, LD)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:LESLIE
Last Name:HARRELL
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 RESOLUTE LN STE 204
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-6687
Mailing Address - Country:US
Mailing Address - Phone:803-814-5392
Mailing Address - Fax:888-965-1379
Practice Address - Street 1:10 RESOLUTE LN STE 204
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-6687
Practice Address - Country:US
Practice Address - Phone:803-814-5392
Practice Address - Fax:888-965-1379
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2503133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty