Provider Demographics
NPI:1841747151
Name:LIGHTY, MCKENZIE L (LMT)
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:L
Last Name:LIGHTY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:MCKENZIE
Other - Middle Name:L
Other - Last Name:WILCOX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:2564 NE COURTNEY DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-7638
Mailing Address - Country:US
Mailing Address - Phone:541-678-5277
Mailing Address - Fax:541-678-5277
Practice Address - Street 1:2564 NE COURTNEY DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-7638
Practice Address - Country:US
Practice Address - Phone:541-678-5277
Practice Address - Fax:541-678-5277
Is Sole Proprietor?:No
Enumeration Date:2016-09-02
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15511225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist