Healthcare Provider Details

I. General information

NPI: 1013468065
Provider Name (Legal Business Name): MACKENZIE ERIN CLEGG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MACKENZIE ERIN SAVILLE

II. Dates (important events)

Enumeration Date: 10/14/2016
Last Update Date: 04/10/2025
Certification Date: 04/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 FULLER AVE NE
GRAND RAPIDS MI
49503-1918
US

IV. Provider business mailing address

14166 8TH AVE
MARNE MI
49435-9759
US

V. Phone/Fax

Practice location:
  • Phone: 616-336-3909
  • Fax: 616-336-8830
Mailing address:
  • Phone: 248-805-2643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: