Provider Demographics
NPI:1073027066
Name:BROWN, MACKENZIE (PSYD)
Entity type:Individual
Prefix:DR
First Name:MACKENZIE
Middle Name:
Last Name:BROWN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:792 S BERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-1519
Mailing Address - Country:US
Mailing Address - Phone:732-567-6544
Mailing Address - Fax:
Practice Address - Street 1:792 S BERMONT AVE
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-1519
Practice Address - Country:US
Practice Address - Phone:732-567-6544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-29
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0005213103TE1100X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & SportsGroup - Multi-Specialty