Provider Demographics
NPI:1609480946
Name:OLIVER, MACKENZIE
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:OLIVER
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 1:2205 OLIVER SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-8876
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:344 FAYETTEVILLE AVE
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:AR
Practice Address - Zip Code:72921-3655
Practice Address - Country:US
Practice Address - Phone:479-434-7995
Practice Address - Fax:479-430-7596
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician