Healthcare Provider Details

I. General information

NPI: 1366435844
Provider Name (Legal Business Name): JAMES ANDREW MACKENZIE PH.D., M.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N 12TH ST # 605 BANNER FAMILY MEDICINE CENTER
PHOENIX AZ
85006-2898
US

IV. Provider business mailing address

11220 N 44TH PL
PHOENIX AZ
85028-3011
US

V. Phone/Fax

Practice location:
  • Phone: 602-239-2638
  • Fax: 602-239-2067
Mailing address:
  • Phone: 602-239-2638
  • Fax: 602-239-2067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number1110
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: