Provider Demographics
NPI:1962205443
Name:DAVIS, MACKENZIE
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 ST. LAWRENCE CIRCLE
Mailing Address - Street 2:ATTN: SUE PRINGLE
Mailing Address - City:SAGAMORE HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44067
Mailing Address - Country:US
Mailing Address - Phone:479-201-6032
Mailing Address - Fax:
Practice Address - Street 1:7100 S WILKINSON WAY
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-2590
Practice Address - Country:US
Practice Address - Phone:419-931-9390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-31
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT021597225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist