Provider Demographics
NPI:1750087250
Name:DEMOTTE, MACKENZIE RENEE
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:RENEE
Last Name:DEMOTTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:RENEE
Other - Last Name:TICE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:58147 COLUMBIA RIVER HWY STE C
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENS
Mailing Address - State:OR
Mailing Address - Zip Code:97051-6229
Mailing Address - Country:US
Mailing Address - Phone:503-396-5322
Mailing Address - Fax:503-410-5678
Practice Address - Street 1:58147 COLUMBIA RIVER HWY STE C
Practice Address - Street 2:
Practice Address - City:SAINT HELENS
Practice Address - State:OR
Practice Address - Zip Code:97051-6229
Practice Address - Country:US
Practice Address - Phone:503-396-5322
Practice Address - Fax:503-410-5678
Is Sole Proprietor?:No
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist