Provider Demographics
NPI:1124427901
Name:MACKENZIE, CONNIE KAY (LCSW)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:KAY
Last Name:MACKENZIE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 734
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95031-0734
Mailing Address - Country:US
Mailing Address - Phone:408-499-5469
Mailing Address - Fax:
Practice Address - Street 1:440 MILL POND DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95125-1406
Practice Address - Country:US
Practice Address - Phone:408-499-5469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-18
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW 61797101YM0800X
LCSW 617971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical