Healthcare Provider Details

I. General information

NPI: 1104487404
Provider Name (Legal Business Name): MAKENZIE MICHELLE MURPHY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E HICKORY AVE
CRESTVIEW FL
32536-2737
US

IV. Provider business mailing address

114 SIDNEY AVE
DEFUNIAK SPRINGS FL
32433-3219
US

V. Phone/Fax

Practice location:
  • Phone: 850-329-8641
  • Fax:
Mailing address:
  • Phone: 850-377-9047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number1-21-11859
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-91004
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-23-64164
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: