Provider Demographics
NPI:1790416402
Name:LESON, MCKENZIE GRACE
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:GRACE
Last Name:LESON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MCKENZIE
Other - Middle Name:GRACE
Other - Last Name:LESON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RBT
Mailing Address - Street 1:3441 FORT CAMPBELL BLVD STE F3
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-6684
Mailing Address - Country:US
Mailing Address - Phone:931-449-0063
Mailing Address - Fax:931-896-2737
Practice Address - Street 1:3441 FORT CAMPBELL BLVD STE F3
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-6684
Practice Address - Country:US
Practice Address - Phone:931-449-0063
Practice Address - Fax:931-896-2737
Is Sole Proprietor?:No
Enumeration Date:2022-06-22
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-22-221540106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
RBT-22-221540OtherBEHAVIOR ANALYSIS CERTIFICATION BOARD