Healthcare Provider Details

I. General information

NPI: 1306619002
Provider Name (Legal Business Name): MACKENZIE LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2023
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 S UNIVERSITY BLVD STE 2F
MOBILE AL
36609-7860
US

IV. Provider business mailing address

7125 HITT RD
MOBILE AL
36695-4431
US

V. Phone/Fax

Practice location:
  • Phone: 251-340-2020
  • Fax: 251-340-2067
Mailing address:
  • Phone: 251-422-1827
  • Fax: 251-340-2067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-308526
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: