Provider Demographics
NPI:1992858203
Name:MACKENZIE, MARYANNE (PT)
Entity Type:Individual
Prefix:MS
First Name:MARYANNE
Middle Name:
Last Name:MACKENZIE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 FIREFLY LN
Mailing Address - Street 2:
Mailing Address - City:HINESBURG
Mailing Address - State:VT
Mailing Address - Zip Code:05461-3149
Mailing Address - Country:US
Mailing Address - Phone:802-482-6657
Mailing Address - Fax:
Practice Address - Street 1:790 COLLEGE PKWY
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-3007
Practice Address - Country:US
Practice Address - Phone:802-847-5138
Practice Address - Fax:802-847-1938
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0400002837225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist