Provider Demographics
NPI:1619745338
Name:WILD, MACKENZIE (MA NCC MFT-A)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:WILD
Suffix:
Gender:F
Credentials:MA NCC MFT-A
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 1452
Mailing Address - Street 2:
Mailing Address - City:HOOD RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97031-0452
Mailing Address - Country:US
Mailing Address - Phone:541-203-0912
Mailing Address - Fax:
Practice Address - Street 1:1029 MAY ST STE G
Practice Address - Street 2:
Practice Address - City:HOOD RIVER
Practice Address - State:OR
Practice Address - Zip Code:97031-1514
Practice Address - Country:US
Practice Address - Phone:541-203-0912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR8141106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist