Provider Demographics
NPI:1902635162
Name:BROSS, MCKINZEY LANE
Entity type:Individual
Prefix:MRS
First Name:MCKINZEY
Middle Name:LANE
Last Name:BROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MCKINZEY
Other - Middle Name:LANE
Other - Last Name:BROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4979 SIDNEY RD SW APT D-103
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98367-7417
Mailing Address - Country:US
Mailing Address - Phone:573-253-5772
Mailing Address - Fax:
Practice Address - Street 1:1605 WOODRIDGE DR SE
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-3818
Practice Address - Country:US
Practice Address - Phone:360-443-2399
Practice Address - Fax:360-443-6121
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACB1573143106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician