Provider Demographics
NPI:1326642331
Name:SOBCZAK, MCKENZIE (TLLP)
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:
Last Name:SOBCZAK
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14165 N FENTON RD STE 201
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-1186
Mailing Address - Country:US
Mailing Address - Phone:810-212-9350
Mailing Address - Fax:833-450-6142
Practice Address - Street 1:14165 N FENTON RD STE 201
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-1186
Practice Address - Country:US
Practice Address - Phone:810-212-9350
Practice Address - Fax:833-450-6142
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361008068103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist