Provider Demographics
NPI:1154973022
Name:WALLIN, MACKENZIE G (BA)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:G
Last Name:WALLIN
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:MILTON
Other - Middle Name:G
Other - Last Name:WALLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:401 W. INTERNATIONAL AIRPORT RD.
Mailing Address - Street 2:SUITE 17
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99518-1168
Mailing Address - Country:US
Mailing Address - Phone:907-770-3656
Mailing Address - Fax:907-562-4503
Practice Address - Street 1:401 W. INTERNATIONAL AIRPORT RD.
Practice Address - Street 2:SUITE 17
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99518-1168
Practice Address - Country:US
Practice Address - Phone:907-770-3656
Practice Address - Fax:907-562-4503
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)