Healthcare Provider Details

I. General information

NPI: 1871019844
Provider Name (Legal Business Name): MACKENZIE TAYLOR RICE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2017
Last Update Date: 09/29/2025
Certification Date: 09/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6202 CONSTITUTION DR STE D
FORT WAYNE IN
46804-1583
US

IV. Provider business mailing address

6202 CONSTITUTION DR STE D
FORT WAYNE IN
46804-1583
US

V. Phone/Fax

Practice location:
  • Phone: 260-432-0066
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39004077A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number20043940A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number20043940B
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: