Provider Demographics
NPI:1194304451
Name:WASHA, MACKENZIE LINN
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:LINN
Last Name:WASHA
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 1:100 RED MOON CIRCLE
Mailing Address - Street 2:TRIBAL OPIOID RESPONSE PROJECT
Mailing Address - City:CONCHO
Mailing Address - State:OK
Mailing Address - Zip Code:73022
Mailing Address - Country:US
Mailing Address - Phone:405-422-7452
Mailing Address - Fax:
Practice Address - Street 1:100 RED MOON CIRCLE
Practice Address - Street 2:TRIBAL OPIOID RESPONSE PROJECT
Practice Address - City:CONCHO
Practice Address - State:OK
Practice Address - Zip Code:73022-7302
Practice Address - Country:US
Practice Address - Phone:405-422-7452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-05
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKD083324170175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist