Provider Demographics
NPI:1942779020
Name:THOMPSON, MACKENZIE LYNN (MS)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:LYNN
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:BREEZY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11697-2105
Mailing Address - Country:US
Mailing Address - Phone:718-474-4771
Mailing Address - Fax:
Practice Address - Street 1:305 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:BREEZY POINT
Practice Address - State:NY
Practice Address - Zip Code:11697-2105
Practice Address - Country:US
Practice Address - Phone:718-474-4771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-18
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023080225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist