Provider Demographics
NPI:1588225593
Name:BRAAK, MACKENZIE DARIANNA (BT)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:DARIANNA
Last Name:BRAAK
Suffix:
Gender:F
Credentials:BT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 STILLWATER DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-9119
Mailing Address - Country:US
Mailing Address - Phone:870-932-3600
Mailing Address - Fax:
Practice Address - Street 1:502 E RACE AVE
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-4417
Practice Address - Country:US
Practice Address - Phone:870-932-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
AR106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No174400000XOther Service ProvidersSpecialist