Provider Demographics
NPI:1881189918
Name:BEDOR, MACKENZIE (LLMSW)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:BEDOR
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8047 BRIDGE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-4146
Mailing Address - Country:US
Mailing Address - Phone:248-804-6357
Mailing Address - Fax:
Practice Address - Street 1:1701 BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48340-3412
Practice Address - Country:US
Practice Address - Phone:248-334-4962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-01
Last Update Date:2018-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801102645104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker