Provider Demographics
NPI:1588400964
Name:DEAR, MACKENZIE (DPT)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:DEAR
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2418 OLD STATE ROUTE 3
Mailing Address - Street 2:
Mailing Address - City:EAST CARONDELET
Mailing Address - State:IL
Mailing Address - Zip Code:62240-1430
Mailing Address - Country:US
Mailing Address - Phone:501-733-7775
Mailing Address - Fax:
Practice Address - Street 1:12303 DE PAUL DR
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2512
Practice Address - Country:US
Practice Address - Phone:501-733-7775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023036809225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist