Provider Demographics
NPI:1457090367
Name:MCCOWEN, MACKENZIE VIVIAN (LLBSW)
Entity Type:Individual
Prefix:MISS
First Name:MACKENZIE
Middle Name:VIVIAN
Last Name:MCCOWEN
Suffix:
Gender:F
Credentials:LLBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:785 CHARLIE CT APT 3D
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-7926
Mailing Address - Country:US
Mailing Address - Phone:269-501-5282
Mailing Address - Fax:
Practice Address - Street 1:5340 HOLIDAY TER STE 9
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-2196
Practice Address - Country:US
Practice Address - Phone:269-381-4446
Practice Address - Fax:269-381-4457
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6852093336171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator