Provider Demographics
NPI:1750426052
Name:MCKENZIE, AUDREY J (ATC)
Entity type:Individual
Prefix:MISS
First Name:AUDREY
Middle Name:J
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 E BRIDGE ST
Mailing Address - Street 2:#19
Mailing Address - City:WESTBROOK
Mailing Address - State:ME
Mailing Address - Zip Code:04092-4800
Mailing Address - Country:US
Mailing Address - Phone:207-854-9244
Mailing Address - Fax:
Practice Address - Street 1:284 CUMBERLAND AVE
Practice Address - Street 2:PORTLAND HIGH SCHOOL
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4927
Practice Address - Country:US
Practice Address - Phone:207-874-8250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAT1092255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer