Healthcare Provider Details

I. General information

NPI: 1407543994
Provider Name (Legal Business Name): MACKENZIE PERILLOUX RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2023
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3623 CALVIN DR
COLUMBUS GA
31904-7915
US

IV. Provider business mailing address

9529 NOAK CIR
EAGLE RIVER AK
99577-8515
US

V. Phone/Fax

Practice location:
  • Phone: 706-940-5100
  • Fax:
Mailing address:
  • Phone: 907-350-8893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-410623
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: