Provider Demographics
NPI:1316295439
Name:DUNHAM, MACKENZIE L (MSW, CDPT)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:L
Last Name:DUNHAM
Suffix:
Gender:F
Credentials:MSW, CDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1678
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98668-1678
Mailing Address - Country:US
Mailing Address - Phone:360-397-8246
Mailing Address - Fax:360-397-8448
Practice Address - Street 1:1601 E FOURTH PLAIN BLVD BLDG 17
Practice Address - Street 2:SUITE A212
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-3753
Practice Address - Country:US
Practice Address - Phone:360-397-8246
Practice Address - Fax:360-397-8448
Is Sole Proprietor?:No
Enumeration Date:2012-08-21
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO 60167093101YA0400X
101YM0800X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health