MEDICARE: MACKENZIE LEIGH TRUEBLOOD BCBA, LBA

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	103K00000X	Behavior Analyst	5005	TX

General Provider Information

NPI Number	:	1447994512
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MACKENZIE LEIGH TRUEBLOOD BCBA, LBA

Provider Business Mailing Address
First Line	:	2211 TRADEWINDS DR
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77459-2328
Country	:	US
Telephone Number	:	636-248-1477
Fax Number	:

Provider Business Practice Location Address
First Line	:	8570 SIENNA SPRINGS BLVD STE A
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77459
Country	:	US
Telephone Number	:	346-450-8600
Fax Number	:

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

Provider Enumeration Date	:	04/25/2022
Last Update Date	:	04/25/2022

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