Provider Demographics
NPI:1881199677
Name:ADAMS, MCKENZI (MS, ATC, LAT, CSCS)
Entity Type:Individual
Prefix:
First Name:MCKENZI
Middle Name:
Last Name:ADAMS
Suffix:
Gender:F
Credentials:MS, ATC, LAT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:397 APPALOOSA AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-7009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 W PARK ST
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-8932
Practice Address - Country:US
Practice Address - Phone:406-496-4296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-26
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2255A2300X
MTATC-LAT-LIC-19012255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer