Provider Demographics
NPI:1295290237
Name:WORRELL, M'KENZIE MARIE
Entity type:Individual
Prefix:
First Name:M'KENZIE
Middle Name:MARIE
Last Name:WORRELL
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 1:3284 N 175 W
Mailing Address - Street 2:
Mailing Address - City:NORTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84414-1581
Mailing Address - Country:US
Mailing Address - Phone:801-389-3679
Mailing Address - Fax:
Practice Address - Street 1:3284 N 175 W
Practice Address - Street 2:
Practice Address - City:NORTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84414-1581
Practice Address - Country:US
Practice Address - Phone:801-389-3679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-04
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT195860085106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician