Provider Demographics
NPI:1316328420
Name:MACKEY, THERESA
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:
Last Name:MACKEY
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 1:19 OXFORD AVENUE
Mailing Address - Street 2:
Mailing Address - City:N. MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758
Mailing Address - Country:US
Mailing Address - Phone:516-403-3215
Mailing Address - Fax:
Practice Address - Street 1:19 OXFORD AVENUE
Practice Address - Street 2:
Practice Address - City:N. MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758
Practice Address - Country:US
Practice Address - Phone:516-403-3215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-15
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst