Provider Demographics
NPI:1154944403
Name:CONDON, MACKENZIE
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:CONDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:142 E 16TH ST APT 12E
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-3507
Mailing Address - Country:US
Mailing Address - Phone:833-646-3222
Mailing Address - Fax:
Practice Address - Street 1:13100 W LISBON RD STE 600
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-2509
Practice Address - Country:US
Practice Address - Phone:833-646-3222
Practice Address - Fax:833-646-3222
Is Sole Proprietor?:No
Enumeration Date:2020-05-21
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100051460Medicaid