Provider Demographics
NPI:1922108885
Name:MCKENZIE, LORETTA KAY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LORETTA
Middle Name:KAY
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2325 W WHITE OAKS DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-7419
Mailing Address - Country:US
Mailing Address - Phone:217-793-3949
Mailing Address - Fax:217-793-3995
Practice Address - Street 1:2325 W WHITE OAKS DR
Practice Address - Street 2:SUITE C
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-7419
Practice Address - Country:US
Practice Address - Phone:217-793-3949
Practice Address - Fax:217-793-3995
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-006007103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
108270OtherHEALTH ALLIANCE
722281OtherHEALTHLINK
IL8432104OtherBLUE CROSS BLUE SHIELD
722281OtherHEALTHLINK
108270OtherHEALTH ALLIANCE