Provider Demographics
NPI:1215518386
Name:TREADWELL, MACKENZIE BLAKE (LCSW)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:BLAKE
Last Name:TREADWELL
Suffix:
Gender:
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 MARQUETTE RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-3038
Mailing Address - Country:US
Mailing Address - Phone:601-825-8800
Mailing Address - Fax:
Practice Address - Street 1:613 MARQUETTE RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-3038
Practice Address - Country:US
Practice Address - Phone:601-825-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-19
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC11413104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker