Provider Demographics
NPI:1679196455
Name:SACK, MACKENZIE WAYNE
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:WAYNE
Last Name:SACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 MANSFIELD ST STE 6
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-3588
Mailing Address - Country:US
Mailing Address - Phone:509-942-1624
Mailing Address - Fax:
Practice Address - Street 1:1305 MANSFIELD ST STE 6
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3588
Practice Address - Country:US
Practice Address - Phone:509-942-1624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-27
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61071424101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)