Healthcare Provider Details

I. General information

NPI: 1962057729
Provider Name (Legal Business Name): PERRIS CHENELLE EDWARDS MCKENZIE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2019
Last Update Date: 04/16/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3068 JOHNSON AVE
COSTA MESA CA
92626-2819
US

IV. Provider business mailing address

400 N TUSTIN AVE STE 120
SANTA ANA CA
92705-3879
US

V. Phone/Fax

Practice location:
  • Phone: 714-545-0644
  • Fax:
Mailing address:
  • Phone: 714-617-4886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number121303
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: