Provider Demographics
NPI:1124889134
Name:PERES, MACKENZIE ANNISA
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:ANNISA
Last Name:PERES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 S INTERSTATE 35 STE 190
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681
Mailing Address - Country:US
Mailing Address - Phone:737-708-8003
Mailing Address - Fax:737-708-8022
Practice Address - Street 1:2400 S INTERSTATE 35 STE 190
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681
Practice Address - Country:US
Practice Address - Phone:737-708-8003
Practice Address - Fax:737-708-8022
Is Sole Proprietor?:No
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician