Provider Demographics
NPI:1801002142
Name:PHERIGO, MACKENZIE R (LCSW, CADC)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:R
Last Name:PHERIGO
Suffix:
Gender:F
Credentials:LCSW, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2148 VADALABENE DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-5632
Mailing Address - Country:US
Mailing Address - Phone:618-288-3100
Mailing Address - Fax:618-288-3371
Practice Address - Street 1:2148 VADALABENE DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5632
Practice Address - Country:US
Practice Address - Phone:618-288-3100
Practice Address - Fax:618-288-3371
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.009882104100000X
IL149.0130081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker