Provider Demographics
NPI:1750948998
Name:MASSUCCI, MCKENZIE RAE
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:RAE
Last Name:MASSUCCI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:238 S MERIDIAN RD
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44509-2925
Mailing Address - Country:US
Mailing Address - Phone:330-318-3436
Mailing Address - Fax:
Practice Address - Street 1:238 S MERIDIAN RD
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44509-2925
Practice Address - Country:US
Practice Address - Phone:330-318-3436
Practice Address - Fax:330-319-8800
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-23
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPP-000246080101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty