Healthcare Provider Details

I. General information

NPI: 1750110680
Provider Name (Legal Business Name): MACKENZIE L MICHEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2024
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 E 32ND ST
JOPLIN MO
64804-3312
US

IV. Provider business mailing address

PO BOX 2526
JOPLIN MO
64803-2526
US

V. Phone/Fax

Practice location:
  • Phone: 417-347-7567
  • Fax:
Mailing address:
  • Phone: 417-347-7579
  • Fax: 417-347-0293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2024029200
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: