Provider Demographics
NPI:1750052874
Name:SMITH, MCKENZIE NICOLE
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 OLD BAPTIST RD
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:TN
Mailing Address - Zip Code:38449-3022
Mailing Address - Country:US
Mailing Address - Phone:931-993-2249
Mailing Address - Fax:
Practice Address - Street 1:810 SHONEY DR SW STE 115
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-5450
Practice Address - Country:US
Practice Address - Phone:931-993-2249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN134407425106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician