Healthcare Provider Details

I. General information

NPI: 1124189261
Provider Name (Legal Business Name): JUNE MACKENZIE LRC LADC I
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

742 MASSACHUSETTS AVENUE
ARLINGTON MA
02476-4712
US

IV. Provider business mailing address

1040 WALTHAM STREET
LEXINGTON MA
02421-8033
US

V. Phone/Fax

Practice location:
  • Phone: 781-646-7301
  • Fax: 781-643-8726
Mailing address:
  • Phone: 781-862-3600
  • Fax: 781-863-5904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: