Provider Demographics
NPI:1619140704
Name:MACKENZIE, MICHAEL CHARLES (MA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:CHARLES
Last Name:MACKENZIE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 STATE HIGHWAY 119
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80504-9538
Mailing Address - Country:US
Mailing Address - Phone:303-520-7781
Mailing Address - Fax:
Practice Address - Street 1:2020 TERRY ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-1893
Practice Address - Country:US
Practice Address - Phone:303-520-7781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3955101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health