Provider Demographics
NPI:1891392809
Name:WELLS, MACKENZIE (MA, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:WELLS
Suffix:
Gender:F
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 S 28TH AVE APT 104
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-2519
Mailing Address - Country:US
Mailing Address - Phone:601-754-8224
Mailing Address - Fax:
Practice Address - Street 1:300 7TH AVE SW
Practice Address - Street 2:
Practice Address - City:MAGEE
Practice Address - State:MS
Practice Address - Zip Code:39111
Practice Address - Country:US
Practice Address - Phone:601-259-1388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-02
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSRBT-20-136750106S00000X
MS220102103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician