Provider Demographics
NPI:1215667167
Name:STOCUM, MACKENZIE M (MS)
Entity type:Individual
Prefix:MS
First Name:MACKENZIE
Middle Name:M
Last Name:STOCUM
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1736 WATERLOO ST APT B
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19122-3217
Mailing Address - Country:US
Mailing Address - Phone:570-772-7180
Mailing Address - Fax:
Practice Address - Street 1:1736 WATERLOO ST # B
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19122-3217
Practice Address - Country:US
Practice Address - Phone:570-772-7180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health