Provider Demographics
NPI:1649022039
Name:FLOYD, MACKENZIE ELIZABETH TIDWELL (MA BCBA)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:ELIZABETH TIDWELL
Last Name:FLOYD
Suffix:
Gender:F
Credentials:MA BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7015 SERF PL
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78252-4580
Mailing Address - Country:US
Mailing Address - Phone:661-889-7596
Mailing Address - Fax:
Practice Address - Street 1:5616 LONE STAR PKWY STE 101
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78253-2201
Practice Address - Country:US
Practice Address - Phone:210-202-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-24-72089103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst