Provider Demographics
NPI:1790488757
Name:BRISCOE, MAKENZIE MARIE
Entity Type:Individual
Prefix:
First Name:MAKENZIE
Middle Name:MARIE
Last Name:BRISCOE
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 1:3032 SE 19TH ST
Mailing Address - Street 2:
Mailing Address - City:DEL CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73115-1510
Mailing Address - Country:US
Mailing Address - Phone:316-347-5096
Mailing Address - Fax:
Practice Address - Street 1:2219 W I 240 SERVICE RD STE 109-115
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-8250
Practice Address - Country:US
Practice Address - Phone:405-355-3239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKRBT-23-265181106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician