MEDICARE: MACKENZIE LEE-ROSS HAROLDSEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1386265817
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MACKENZIE LEE-ROSS HAROLDSEN

Provider Business Mailing Address
First Line	:	4733 W THORNDALE WAY
Second Line	:
City	:	WEST JORDAN
State	:	UT
Zip	:	84084-5697
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7138 S HIGHLAND DR STE 106
Second Line	:
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84121-3775
Country	:	US
Telephone Number	:	801-942-1800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/06/2020
Last Update Date	:	08/11/2022

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