Provider Demographics
NPI:1952020158
Name:PRENDERGAST, MACKENZIE (LCSW)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:PRENDERGAST
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:645 S ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2353
Mailing Address - Country:US
Mailing Address - Phone:812-339-1691
Mailing Address - Fax:
Practice Address - Street 1:1156 OLD STATE ROAD 46
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:IN
Practice Address - Zip Code:47448-9211
Practice Address - Country:US
Practice Address - Phone:812-988-2258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34009859A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical