Healthcare Provider Details

I. General information

NPI: 1013386333
Provider Name (Legal Business Name): MACKENZIE MCNABB
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2015
Last Update Date: 12/28/2021
Certification Date: 09/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1266 14TH ST
OAKLAND CA
94607-2247
US

IV. Provider business mailing address

7200 BANCROFT AVE STE 220
OAKLAND CA
94605-2414
US

V. Phone/Fax

Practice location:
  • Phone: 510-273-4700
  • Fax:
Mailing address:
  • Phone: 510-553-1333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number96943
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number76844
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: