Provider Demographics
NPI:1639476039
Name:DAKE, MACKENZIE N (PT)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:N
Last Name:DAKE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:N
Other - Last Name:MASON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:408 HIGUERA ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-6135
Mailing Address - Country:US
Mailing Address - Phone:805-788-0805
Mailing Address - Fax:805-788-0845
Practice Address - Street 1:1414 PARK ST
Practice Address - Street 2:
Practice Address - City:PASO ROBLES
Practice Address - State:CA
Practice Address - Zip Code:93446-2160
Practice Address - Country:US
Practice Address - Phone:805-226-0975
Practice Address - Fax:805-226-0909
Is Sole Proprietor?:No
Enumeration Date:2011-02-21
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT37580225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAER990ZMedicare PIN