Provider Demographics
NPI:1740587666
Name:MACKENZIE, KELLEY ELIZABETH (MS, LADC)
Entity Type:Individual
Prefix:MS
First Name:KELLEY
Middle Name:ELIZABETH
Last Name:MACKENZIE
Suffix:
Gender:F
Credentials:MS, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:650 MAIN ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-5448
Mailing Address - Country:US
Mailing Address - Phone:207-774-4564
Mailing Address - Fax:207-774-0006
Practice Address - Street 1:650 MAIN ST
Practice Address - Street 2:SUITE 103
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-5448
Practice Address - Country:US
Practice Address - Phone:207-774-4564
Practice Address - Fax:207-774-0006
Is Sole Proprietor?:No
Enumeration Date:2011-02-13
Last Update Date:2011-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC3942101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)