Provider Demographics
NPI:1154041473
Name:MOORE, MACKENZIE (PT, DPT)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 JONES ST
Mailing Address - Street 2:
Mailing Address - City:LECOMPTON
Mailing Address - State:KS
Mailing Address - Zip Code:66050-3032
Mailing Address - Country:US
Mailing Address - Phone:402-320-8411
Mailing Address - Fax:
Practice Address - Street 1:1401 CONOWINGO RD STE C
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-1809
Practice Address - Country:US
Practice Address - Phone:402-320-8411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD29146225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist