Provider Demographics
NPI:1972003374
Name:ADAMS, MACKENZIE (ATC, LAT)
Entity Type:Individual
Prefix:MS
First Name:MACKENZIE
Middle Name:
Last Name:ADAMS
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 MARKETPLACE DR APT 224
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76711-2435
Mailing Address - Country:US
Mailing Address - Phone:269-221-4823
Mailing Address - Fax:
Practice Address - Street 1:1202 N ELLIS ST
Practice Address - Street 2:
Practice Address - City:GROESBECK
Practice Address - State:TX
Practice Address - Zip Code:76642-2111
Practice Address - Country:US
Practice Address - Phone:254-729-4630
Practice Address - Fax:254-729-4630
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-13
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT62792255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty