Provider Demographics
NPI:1013277805
Name:MACKENZIE, MIRIAM C (MED)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:C
Last Name:MACKENZIE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 SUMMER ST STE 202
Mailing Address - Street 2:
Mailing Address - City:TAUNTON
Mailing Address - State:MA
Mailing Address - Zip Code:02780-3469
Mailing Address - Country:US
Mailing Address - Phone:508-269-8262
Mailing Address - Fax:508-822-2601
Practice Address - Street 1:30 BEECHWOOD DR
Practice Address - Street 2:
Practice Address - City:MASHPEE
Practice Address - State:MA
Practice Address - Zip Code:02649-2334
Practice Address - Country:US
Practice Address - Phone:508-269-8262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-25
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9534556390200000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program