Provider Demographics
NPI:1639676950
Name:FOX, MACKENZIE LYNN (MS)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:LYNN
Last Name:FOX
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:KENZIE
Other - Middle Name:
Other - Last Name:FOX
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:W417 SUNSHINE DR
Mailing Address - Street 2:
Mailing Address - City:STODDARD
Mailing Address - State:WI
Mailing Address - Zip Code:54658-9059
Mailing Address - Country:US
Mailing Address - Phone:651-707-5137
Mailing Address - Fax:
Practice Address - Street 1:W417 SUNSHINE DR
Practice Address - Street 2:
Practice Address - City:STODDARD
Practice Address - State:WI
Practice Address - Zip Code:54658-9059
Practice Address - Country:US
Practice Address - Phone:651-707-5137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-12
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4142-226101YP2500X
WI8039-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional