Provider Demographics
NPI:1730324278
Name:MCKENZIE, LATISHA (DPT)
Entity Type:Individual
Prefix:
First Name:LATISHA
Middle Name:
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4027 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1544
Mailing Address - Country:US
Mailing Address - Phone:267-297-6499
Mailing Address - Fax:267-297-6614
Practice Address - Street 1:4027 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19129-1544
Practice Address - Country:US
Practice Address - Phone:267-297-6499
Practice Address - Fax:267-297-6614
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-12
Last Update Date:2016-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1030093800001Medicaid