Provider Demographics
NPI:1538709548
Name:MINARD, MACKENZIE ILENE
Entity type:Individual
Prefix:MISS
First Name:MACKENZIE
Middle Name:ILENE
Last Name:MINARD
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 1:34691 BELLA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-4592
Mailing Address - Country:US
Mailing Address - Phone:909-800-7108
Mailing Address - Fax:
Practice Address - Street 1:198 JUANA AVE
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4808
Practice Address - Country:US
Practice Address - Phone:510-822-2915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst