Provider Demographics
NPI:1821628116
Name:KOSTIZEN, MACKENZIE (MA)
Entity Type:Individual
Prefix:MS
First Name:MACKENZIE
Middle Name:
Last Name:KOSTIZEN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:364 BALDWIN RD
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-1360
Mailing Address - Country:US
Mailing Address - Phone:248-703-2075
Mailing Address - Fax:
Practice Address - Street 1:31700 W 12 MILE RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-4424
Practice Address - Country:US
Practice Address - Phone:734-368-7154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-25
Last Update Date:2023-01-27
Deactivation Date:2020-12-14
Deactivation Code:
Reactivation Date:2023-01-27
Provider Licenses
StateLicense IDTaxonomies
MI6352000115103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical