Provider Demographics
NPI:1306496559
Name:JOHNSTON, MACKENZIE DENISE
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:DENISE
Last Name:JOHNSTON
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 1:2220 BIRD ST APT 1231
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76111-1394
Mailing Address - Country:US
Mailing Address - Phone:806-290-3940
Mailing Address - Fax:
Practice Address - Street 1:6251 OVERTON RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-3755
Practice Address - Country:US
Practice Address - Phone:866-891-1294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-18
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2149211225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant