Provider Demographics
NPI:1356063127
Name:MACKENZIE, DOAN (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:DOAN
Middle Name:
Last Name:MACKENZIE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1470 LINDSAY LN
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-4251
Mailing Address - Country:US
Mailing Address - Phone:718-309-6183
Mailing Address - Fax:
Practice Address - Street 1:12380 DE PAUL DR
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2511
Practice Address - Country:US
Practice Address - Phone:314-447-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-16
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022030883225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist