Provider Demographics
NPI:1700905957
Name:MCKENZIE, ROBERT WAYNE (PHD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:WAYNE
Last Name:MCKENZIE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 W CONNALLY ST
Mailing Address - Street 2:P.O. BOX 0297
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1404
Mailing Address - Country:US
Mailing Address - Phone:903-752-1004
Mailing Address - Fax:903-683-3212
Practice Address - Street 1:933 W CONNALLY ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1404
Practice Address - Country:US
Practice Address - Phone:903-581-5714
Practice Address - Fax:903-534-1507
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25161103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX100340204Medicaid
TXP00254134OtherRAIL ROAD MEDICARE
TXP00254134OtherRAIL ROAD MEDICARE
TXP00254134Medicare PIN