Healthcare Provider Details

I. General information

NPI: 1174457410
Provider Name (Legal Business Name): MACKENZIE BECKELY LEP, PPSP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17772 IRVINE BLVD STE 103
TUSTIN CA
92780-3233
US

IV. Provider business mailing address

1939 WALLACE AVE APT 109
COSTA MESA CA
92627-3492
US

V. Phone/Fax

Practice location:
  • Phone: 949-232-7645
  • Fax:
Mailing address:
  • Phone: 949-232-7645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number260126195
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: