Healthcare Provider Details

I. General information

NPI: 1720887805
Provider Name (Legal Business Name): MACKENZIE KEMPER
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2025
Last Update Date: 03/11/2025
Certification Date: 03/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 W OAKLEY ST
FLINT MI
48503-3915
US

IV. Provider business mailing address

310 W OAKLEY ST
FLINT MI
48503-3915
US

V. Phone/Fax

Practice location:
  • Phone: 810-877-6932
  • Fax:
Mailing address:
  • Phone: 810-877-6932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: