MEDICARE: MACKENZIE LANE LSW

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	104100000X	Social Worker	S.2004686	OH

General Provider Information

NPI Number	:	1639811839
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MACKENZIE LANE LSW

Provider Business Mailing Address
First Line	:	2775 ORCHARD RUN RD
Second Line	:	PMB 402
City	:	DAYTON
State	:	OH
Zip	:	45449
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5320 BROMWICK DR
Second Line	:
City	:	TROTWOOD
State	:	OH
Zip	:	45426-1912
Country	:	US
Telephone Number	:	937-204-3858
Fax Number	:

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

Provider Enumeration Date	:	04/08/2022
Last Update Date	:	03/26/2026

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Directions to “ MACKENZIE LANE LSW” Practice Location

Language	Start Address	Practice Location

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