Provider Demographics
NPI:1528945839
Name:BLACKWELL, MACKENZIE R
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:R
Last Name:BLACKWELL
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 1:6799 E TEXAS ST
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-6931
Mailing Address - Country:US
Mailing Address - Phone:318-616-2336
Mailing Address - Fax:318-616-1857
Practice Address - Street 1:6799 E TEXAS ST
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-6931
Practice Address - Country:US
Practice Address - Phone:318-616-2336
Practice Address - Fax:318-616-2336
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-19
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAC-179106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Multi-Specialty