Provider Demographics
NPI:1104953165
Name:MACKENZIE, CONNIE L (PT)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:L
Last Name:MACKENZIE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 PEACHTREE STREET
Mailing Address - Street 2:SUITE 1900
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308
Mailing Address - Country:US
Mailing Address - Phone:404-215-2050
Mailing Address - Fax:404-215-2051
Practice Address - Street 1:550 PEACHTREE STREET
Practice Address - Street 2:SUITE 1900
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308
Practice Address - Country:US
Practice Address - Phone:404-215-2050
Practice Address - Fax:404-215-2051
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT005653225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist