Provider Demographics
NPI:1295133643
Name:HARDIN, MACKENZIE (PTA)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:HARDIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N14289 ARNDT RD
Mailing Address - Street 2:
Mailing Address - City:FAIRCHILD
Mailing Address - State:WI
Mailing Address - Zip Code:54741-8862
Mailing Address - Country:US
Mailing Address - Phone:715-533-0031
Mailing Address - Fax:
Practice Address - Street 1:1405 TRUAX BLVD
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703-1474
Practice Address - Country:US
Practice Address - Phone:715-552-1030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-17
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2217-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant