Healthcare Provider Details

I. General information

NPI: 1760071583
Provider Name (Legal Business Name): MRS. MACKENZIE BERNAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2021
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

533 VERSAILLES DR STE 200
MAITLAND FL
32751-7303
US

IV. Provider business mailing address

3900 SOUTHPOINTE DR APT 117
ORLANDO FL
32822-3719
US

V. Phone/Fax

Practice location:
  • Phone: 407-308-0345
  • Fax:
Mailing address:
  • Phone: 407-488-2588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMT4541
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: