Provider Demographics
NPI:1104553015
Name:MINTON, MCKENZIE (BCBA)
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:
Last Name:MINTON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:MCKENZIE
Other - Middle Name:
Other - Last Name:LAWSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 32665
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37930-2665
Mailing Address - Country:US
Mailing Address - Phone:865-312-8220
Mailing Address - Fax:833-550-1727
Practice Address - Street 1:2484 BRIGHTS PIKE
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814
Practice Address - Country:US
Practice Address - Phone:865-312-8220
Practice Address - Fax:833-550-1727
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
1-24-72850103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician