Provider Demographics
NPI:1598015539
Name:CROLL MACKENZIE, BETH
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:CROLL MACKENZIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 ELLEN ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-4009
Mailing Address - Country:US
Mailing Address - Phone:315-343-1708
Mailing Address - Fax:
Practice Address - Street 1:216 COUNTY ROUTE 64
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:NY
Practice Address - Zip Code:13114-3229
Practice Address - Country:US
Practice Address - Phone:315-963-0864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist