Provider Demographics
NPI:1720586209
Name:MACKENZIE, BREE ANNE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:BREE
Middle Name:ANNE
Last Name:MACKENZIE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:382 PARTRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-3593
Mailing Address - Country:US
Mailing Address - Phone:208-351-1599
Mailing Address - Fax:
Practice Address - Street 1:382 PARTRIDGE LN
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-3593
Practice Address - Country:US
Practice Address - Phone:208-351-1599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-30
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA-5317225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant