Provider Demographics
NPI:1780228171
Name:LAFORTUNE, MACKENSON
Entity Type:Individual
Prefix:
First Name:MACKENSON
Middle Name:
Last Name:LAFORTUNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1424 FILIGREE PL
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-7528
Mailing Address - Country:US
Mailing Address - Phone:678-790-2882
Mailing Address - Fax:
Practice Address - Street 1:1424 FILIGREE PL
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019
Practice Address - Country:US
Practice Address - Phone:678-790-2882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-29
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL225200000X
GA225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant