Provider Demographics
NPI:1659371664
Name:MCKENZIE, LACY BRENNA (MS NCC LPC)
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:BRENNA
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:MS NCC LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3949 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97603-4746
Mailing Address - Country:US
Mailing Address - Phone:800-552-6290
Mailing Address - Fax:541-880-0560
Practice Address - Street 1:3949 S 6TH ST
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97603-4746
Practice Address - Country:US
Practice Address - Phone:800-552-6290
Practice Address - Fax:541-880-0560
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC1364101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR129861Medicaid
ORC1364OtherCERTIFICATION NUMBER