Provider Demographics
NPI:1609971993
Name:MACKENZIE, HEATHER L (PA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:L
Last Name:MACKENZIE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 255228
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95865-5228
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:1340 LAKE BLVD
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-5673
Practice Address - Country:US
Practice Address - Phone:530-753-5338
Practice Address - Fax:530-759-7469
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT21240225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0212400Medicaid
0PT212400Medicare ID - Type Unspecified
CAPT0212400Medicaid