Provider Demographics
NPI:1154989093
Name:ANDREOLLI, MACKENZIE
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:ANDREOLLI
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 1:2801 W BANCROFT ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-3328
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2801 W BANCROFT ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3328
Practice Address - Country:US
Practice Address - Phone:248-804-1927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer