Healthcare Provider Details

I. General information

NPI: 1790656304
Provider Name (Legal Business Name): MACKENZIE MOAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2025
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 BIRCH LN
DAVIS CA
95618-1450
US

IV. Provider business mailing address

1600 BIRCH LN
DAVIS CA
95618-1450
US

V. Phone/Fax

Practice location:
  • Phone: 530-757-5395
  • Fax:
Mailing address:
  • Phone: 530-757-5395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number250140594
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: