Provider Demographics
NPI:1619581485
Name:MCKENZIE, NIKOLA
Entity Type:Individual
Prefix:
First Name:NIKOLA
Middle Name:
Last Name:MCKENZIE
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 1:209 E GORDON AVE
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-2341
Mailing Address - Country:US
Mailing Address - Phone:801-549-8821
Mailing Address - Fax:801-513-5608
Practice Address - Street 1:209 E GORDON AVE
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-2341
Practice Address - Country:US
Practice Address - Phone:801-549-2281
Practice Address - Fax:801-513-5608
Is Sole Proprietor?:No
Enumeration Date:2020-08-31
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
UT1-21-50814103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician