Provider Demographics
NPI:1255984969
Name:TAYLOR, MACKENZIE LEE
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:LEE
Last Name:TAYLOR
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 1:9426 LIMA RD STE A
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46818-8681
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:118 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:MILLERSBURG
Practice Address - State:IN
Practice Address - Zip Code:46543
Practice Address - Country:US
Practice Address - Phone:574-238-5566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist