Healthcare Provider Details

I. General information

NPI: 1467519082
Provider Name (Legal Business Name): TIFFANY JACQUELINE MCKENZIE MA, LPA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 06/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8390 SIX FORKS RD SUITE #201
RALEIGH NC
27615-3060
US

IV. Provider business mailing address

2013 WATERTON LN
APEX NC
27502-9003
US

V. Phone/Fax

Practice location:
  • Phone: 919-782-8730
  • Fax: 919-782-8731
Mailing address:
  • Phone: 919-303-4941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2424
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: