Provider Demographics
NPI:1336761444
Name:ANDERSON, MACKENZIE (LADC, CCS)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LADC, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 DIGITAL DR
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-4418
Mailing Address - Country:US
Mailing Address - Phone:207-800-3347
Mailing Address - Fax:
Practice Address - Street 1:6 DIGITAL DR
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-4418
Practice Address - Country:US
Practice Address - Phone:207-800-3347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-12
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECCS7931101YA0400X
MELC7602101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MECCS7931OtherCCS
MELC7602OtherLADC