Provider Demographics
NPI:1457356404
Name:MACKENZIE, WILLIAM R (PT)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:R
Last Name:MACKENZIE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11802 NE 65TH ST
Mailing Address - Street 2:100
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-5521
Mailing Address - Country:US
Mailing Address - Phone:360-253-6883
Mailing Address - Fax:360-892-7040
Practice Address - Street 1:11802 NE 65TH ST
Practice Address - Street 2:100
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-5521
Practice Address - Country:US
Practice Address - Phone:360-253-6883
Practice Address - Fax:360-892-7040
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00006628225100000X
WACH00034484111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA192088OtherDEPT OF LABOR &IND.
WA8412983Medicaid
WA8412983Medicaid