Provider Demographics
NPI:1679208987
Name:MOORE, MACKENZIE CAROL (MS COUNSELING)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:CAROL
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS COUNSELING
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:659 OAK RESERVE LN
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-3057
Mailing Address - Country:US
Mailing Address - Phone:213-680-5893
Mailing Address - Fax:
Practice Address - Street 1:2479 ALOMA AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-2541
Practice Address - Country:US
Practice Address - Phone:407-657-6692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-20
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH22658101YM0800X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor