Provider Demographics
NPI:1154107944
Name:SUMMERS, MACKENZIE RAE (MOTR/L)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:RAE
Last Name:SUMMERS
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:KENZIE
Other - Middle Name:RAE
Other - Last Name:SUMMERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MOTR/L
Mailing Address - Street 1:1019 VALLEY VIEW AVE APT B8
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-3516
Mailing Address - Country:US
Mailing Address - Phone:304-494-1792
Mailing Address - Fax:304-494-1792
Practice Address - Street 1:1543 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-1306
Practice Address - Country:US
Practice Address - Phone:304-363-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2395225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty