Healthcare Provider Details

I. General information

NPI: 1609640929
Provider Name (Legal Business Name): DAMON MCKENZIE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2023
Last Update Date: 12/18/2023
Certification Date: 12/18/2023
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: 479-965-5443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: DAMON MARK MCKENZIE
Title or Position: COUNSELOR
Credential: LPC
Phone: 479-965-5443