Healthcare Provider Details

I. General information

NPI: 1891291290
Provider Name (Legal Business Name): DAMON MARK MCKENZIE LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 POINT ROYAL LOOP
CHARLESTON AR
72933-8239
US

IV. Provider business mailing address

1234 POINT ROYAL LOOP
CHARLESTON AR
72933-8239
US

V. Phone/Fax

Practice location:
  • Phone: 479-965-5443
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA1802018
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP2103167
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: