Provider Demographics
NPI:1629886833
Name:GRUBBS, MCKENZIE NICOLE (PCLC)
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:NICOLE
Last Name:GRUBBS
Suffix:
Gender:F
Credentials:PCLC
Other - Prefix:
Other - First Name:MCKENZIE
Other - Middle Name:NICOLE
Other - Last Name:POULSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1750 RAY OF HOPE LN
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59106-3502
Mailing Address - Country:US
Mailing Address - Phone:406-656-2198
Mailing Address - Fax:
Practice Address - Street 1:1750 RAY OF HOPE LN
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59106-3502
Practice Address - Country:US
Practice Address - Phone:406-656-2198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-19
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-PCLC-LIC-69819101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health