Provider Demographics
NPI:1811888647
Name:COLLETON, MACKENZIE LAKE (DPT)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:LAKE
Last Name:COLLETON
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 1:1901 LIBBIE AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-1808
Mailing Address - Country:US
Mailing Address - Phone:804-281-2501
Mailing Address - Fax:
Practice Address - Street 1:1901 LIBBIE AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1808
Practice Address - Country:US
Practice Address - Phone:804-281-3501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-10
Last Update Date:2025-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305214334225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist