Healthcare Provider Details

I. General information

NPI: 1033089727
Provider Name (Legal Business Name): YMAHNE SIMONE MCKENZIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2644 RIVA RD
ANNAPOLIS MD
21401-7427
US

IV. Provider business mailing address

279 RED CLAY RD APT 102
LAUREL MD
20724-2326
US

V. Phone/Fax

Practice location:
  • Phone: 410-555-2000
  • Fax:
Mailing address:
  • Phone: 718-490-7858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number39074
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: