Provider Demographics
NPI:1831692755
Name:MODRALL, MACKENZIE (OTRL)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:MODRALL
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5259 S GLEN OAK DR
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-1764
Mailing Address - Country:US
Mailing Address - Phone:989-280-9555
Mailing Address - Fax:
Practice Address - Street 1:1447 N. HARRISON ST
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-4860
Practice Address - Country:US
Practice Address - Phone:989-280-9555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-16
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201010097225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist