Provider Demographics
NPI:1184717092
Name:MACKENZIE, CATHERINE SC (MA LCSW)
Entity type:Individual
Prefix:
First Name:CATHERINE
Middle Name:SC
Last Name:MACKENZIE
Suffix:
Gender:F
Credentials:MA LCSW
Other - Prefix:
Other - First Name:K
Other - Middle Name:SCOTT
Other - Last Name:MENDELSOHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1415 EAST GREEN BAY ST.
Mailing Address - Street 2:SUITE 191
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-3881
Mailing Address - Country:US
Mailing Address - Phone:715-526-5466
Mailing Address - Fax:715-526-5545
Practice Address - Street 1:444 SOUTH ADAMS ST
Practice Address - Street 2:SUITE 6
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301
Practice Address - Country:US
Practice Address - Phone:715-526-5466
Practice Address - Fax:715-526-5545
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2261123101Y00000X
WI101YM0800X
WI2261-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
11661651OtherCAQH
WI39737500Medicaid