Provider Demographics
NPI:1255745352
Name:LEE, MAKENZIE
Entity type:Individual
Prefix:MR
First Name:MAKENZIE
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9925 W RUSSELL RD UNIT 2040
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-5601
Mailing Address - Country:US
Mailing Address - Phone:623-241-3968
Mailing Address - Fax:
Practice Address - Street 1:9925 W RUSSELL RD UNIT 2040
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-5601
Practice Address - Country:US
Practice Address - Phone:623-241-3968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV101YM0800XMedicaid