Provider Demographics
NPI:1659805182
Name:MCKENZIE, TERA R
Entity Type:Individual
Prefix:
First Name:TERA
Middle Name:R
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:473747 STATE HIGHWAY 101
Mailing Address - Street 2:
Mailing Address - City:MULDROW
Mailing Address - State:OK
Mailing Address - Zip Code:74948-6489
Mailing Address - Country:US
Mailing Address - Phone:918-776-5290
Mailing Address - Fax:
Practice Address - Street 1:473747 STATE HIGHWAY 101
Practice Address - Street 2:
Practice Address - City:MULDROW
Practice Address - State:OK
Practice Address - Zip Code:74948-6489
Practice Address - Country:US
Practice Address - Phone:918-776-5290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health