Provider Demographics
NPI:1932344371
Name:PERGOLOTTI, MACKENZI (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:MACKENZI
Middle Name:
Last Name:PERGOLOTTI
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 HOMEGATE CIR
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-3987
Mailing Address - Country:US
Mailing Address - Phone:919-267-5833
Mailing Address - Fax:
Practice Address - Street 1:1321 WYNNCREST CT
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27603-8768
Practice Address - Country:US
Practice Address - Phone:919-358-7089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-15
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6734225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC250188Medicare PIN