Provider Demographics
NPI:1972008993
Name:GREENLEE, MACKENZIE GRACE (MA)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:GRACE
Last Name:GREENLEE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3737 MORAGA AVE STE A203
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-5491
Mailing Address - Country:US
Mailing Address - Phone:619-363-1920
Mailing Address - Fax:
Practice Address - Street 1:3737 MORAGA AVE STE A203
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-5491
Practice Address - Country:US
Practice Address - Phone:619-363-1920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-30
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA117319106H00000X
CA124064106H00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist