Provider Demographics
NPI:1972937092
Name:MACKENZIE, DIANE E (LCPC)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:E
Last Name:MACKENZIE
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:MACKENZIE
Other - Last Name:MCCANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC
Mailing Address - Street 1:5407 N CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21210-2024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5407 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21210-2024
Practice Address - Country:US
Practice Address - Phone:410-433-8861
Practice Address - Fax:410-433-1249
Is Sole Proprietor?:No
Enumeration Date:2013-08-26
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC1724101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional