Provider Demographics
NPI:1568116077
Name:MINER, MACKENZIE PAIGE
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:PAIGE
Last Name:MINER
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 1:6319 FLY RD STE 4
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-4900
Mailing Address - Country:US
Mailing Address - Phone:718-215-5311
Mailing Address - Fax:718-865-5165
Practice Address - Street 1:6319 FLY RD STE 4
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-4900
Practice Address - Country:US
Practice Address - Phone:718-215-5311
Practice Address - Fax:718-865-5165
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-04
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NY24-389172106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician