Provider Demographics
NPI:1790383966
Name:BROEKSTRA, MCKENZIE (LSW; LMSW)
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:
Last Name:BROEKSTRA
Suffix:
Gender:F
Credentials:LSW; LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 ANYHOW LN
Mailing Address - Street 2:
Mailing Address - City:GANSEVOORT
Mailing Address - State:NY
Mailing Address - Zip Code:12831-1710
Mailing Address - Country:US
Mailing Address - Phone:616-446-3126
Mailing Address - Fax:
Practice Address - Street 1:6 ANYHOW LN
Practice Address - Street 2:
Practice Address - City:GANSEVOORT
Practice Address - State:NY
Practice Address - Zip Code:12831-1710
Practice Address - Country:US
Practice Address - Phone:616-446-3126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-11
Last Update Date:2020-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLSW.0009922840104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker