Healthcare Provider Details

I. General information

NPI: 1447952528
Provider Name (Legal Business Name): MCKENZIE ROSE GANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2023
Last Update Date: 06/27/2024
Certification Date: 06/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 FAIR AVE
SANTA CRUZ CA
95060-5828
US

IV. Provider business mailing address

707 FAIR AVE
SANTA CRUZ CA
95060-5828
US

V. Phone/Fax

Practice location:
  • Phone: 831-427-1007
  • Fax: 831-454-0545
Mailing address:
  • Phone: 831-427-1007
  • Fax: 831-454-0545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: