Provider Demographics
NPI:1306584339
Name:LYTTLE, MACKENZIE CHRISTINE (DPT)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:CHRISTINE
Last Name:LYTTLE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:
Other - Last Name:DAVIDGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:1446 SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-2088
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1512 W SERVICE DR
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-2540
Practice Address - Country:US
Practice Address - Phone:507-474-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-20
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12603225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist