Provider Demographics
NPI:1992211098
Name:KWAKENAT, MACY
Entity Type:Individual
Prefix:
First Name:MACY
Middle Name:
Last Name:KWAKENAT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:278 MISSION TRACE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-1176
Mailing Address - Country:US
Mailing Address - Phone:407-766-0223
Mailing Address - Fax:
Practice Address - Street 1:166 A1A N
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-5701
Practice Address - Country:US
Practice Address - Phone:904-395-3468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-27
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-17-33350106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician