Provider Demographics
NPI:1932434685
Name:MACKENZIE, LYNNETTE D (PSYD)
Entity Type:Individual
Prefix:
First Name:LYNNETTE
Middle Name:D
Last Name:MACKENZIE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 ARLINGTON AVE N
Mailing Address - Street 2:305
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-3652
Mailing Address - Country:US
Mailing Address - Phone:727-412-8003
Mailing Address - Fax:866-469-3880
Practice Address - Street 1:4625 E BAY DR
Practice Address - Street 2:302
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33764-5738
Practice Address - Country:US
Practice Address - Phone:727-412-8000
Practice Address - Fax:866-469-3880
Is Sole Proprietor?:No
Enumeration Date:2009-10-14
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7984103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist