Provider Demographics
NPI:1104594670
Name:THORSRUD, MACKENZIE E (MED, NCC, LAC)
Entity type:Individual
Prefix:MRS
First Name:MACKENZIE
Middle Name:E
Last Name:THORSRUD
Suffix:
Gender:F
Credentials:MED, NCC, LAC
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:E
Other - Last Name:DEAKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2020 S MCCLINTOCK DR STE 101
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-2691
Mailing Address - Country:US
Mailing Address - Phone:520-955-8507
Mailing Address - Fax:
Practice Address - Street 1:2020 S MCCLINTOCK DR STE 101
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-2691
Practice Address - Country:US
Practice Address - Phone:520-955-8507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-20241101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health