Provider Demographics
NPI:1316621303
Name:BRYAN, MACKENZIE ELGAEN
Entity type:Individual
Prefix:MRS
First Name:MACKENZIE
Middle Name:ELGAEN
Last Name:BRYAN
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 1:3662 CEDARCREST RD STE 220
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-8940
Mailing Address - Country:US
Mailing Address - Phone:470-531-0510
Mailing Address - Fax:
Practice Address - Street 1:3662 CEDARCREST RD STE 220
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-8940
Practice Address - Country:US
Practice Address - Phone:470-531-0510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician