Provider Demographics
NPI:1336929231
Name:CORDOVA, MACKENZIE (LCSW)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:CORDOVA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 FISHER AVE APT 202
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02120-3390
Mailing Address - Country:US
Mailing Address - Phone:918-527-9578
Mailing Address - Fax:
Practice Address - Street 1:450 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5450
Practice Address - Country:US
Practice Address - Phone:857-215-2828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALCSW229661104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker