Healthcare Provider Details

I. General information

NPI: 1801646880
Provider Name (Legal Business Name): MACKENZIE LYNN CANFIELD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2024
Last Update Date: 03/25/2024
Certification Date: 03/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

938 N CALIFORNIA AVE
CHICAGO IL
60622-4462
US

IV. Provider business mailing address

3508 W FULLERTON AVE # 3
CHICAGO IL
60647-2418
US

V. Phone/Fax

Practice location:
  • Phone: 312-620-0408
  • Fax:
Mailing address:
  • Phone: 440-804-4149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.026832
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: