Provider Demographics
NPI:1639708613
Name:MACUCH, MACKENZIE (OT)
Entity Type:Individual
Prefix:MS
First Name:MACKENZIE
Middle Name:
Last Name:MACUCH
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 VIRGINIA DR
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02347-1725
Mailing Address - Country:US
Mailing Address - Phone:774-766-9886
Mailing Address - Fax:
Practice Address - Street 1:150 YORK ST
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:MA
Practice Address - Zip Code:02072-1829
Practice Address - Country:US
Practice Address - Phone:781-344-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-02
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA13550225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist