Healthcare Provider Details

I. General information

NPI: 1992458046
Provider Name (Legal Business Name): MRS. MACKENZIE B HENDRICKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2022
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 E CHURCH ST
FORT VALLEY GA
31030-3097
US

IV. Provider business mailing address

301 S CORDER RD APT 817
WARNER ROBINS GA
31088-5719
US

V. Phone/Fax

Practice location:
  • Phone: 478-825-6499
  • Fax:
Mailing address:
  • Phone: 478-335-3178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: