Healthcare Provider Details

I. General information

NPI: 1952858953
Provider Name (Legal Business Name): MCKENZIE 21ST CENTURY CONSULTING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2016
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 W BAYOU PINES DR STE D
LAKE CHARLES LA
70601-7096
US

IV. Provider business mailing address

3548 SAINT NICK ST
LAKE CHARLES LA
70607-7595
US

V. Phone/Fax

Practice location:
  • Phone: 337-508-9023
  • Fax:
Mailing address:
  • Phone: 337-508-9023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: SHAKERA L MCKENZIE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 337-508-9023