Healthcare Provider Details

I. General information

NPI: 1063061430
Provider Name (Legal Business Name): MACKENZIE HUFFMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2019
Last Update Date: 03/06/2020
Certification Date: 03/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5001 CR WOOD RD
GASTONIA NC
28056-8919
US

IV. Provider business mailing address

5001 CR WOOD RD
GASTONIA NC
28056-8919
US

V. Phone/Fax

Practice location:
  • Phone: 704-862-0095
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA14977
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: