Provider Demographics
NPI:1699431114
Name:FAY, MACKENZIE (LPC)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:FAY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:495 SHORE DR
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-6230
Mailing Address - Country:US
Mailing Address - Phone:203-414-2082
Mailing Address - Fax:
Practice Address - Street 1:1372 SUMMER ST STE 300
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5361
Practice Address - Country:US
Practice Address - Phone:203-859-9335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5050101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional