Healthcare Provider Details

I. General information

NPI: 1962345652
Provider Name (Legal Business Name): MAKENZIE MATHEWS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2026
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12811 Q ST
OMAHA NE
68137-3211
US

IV. Provider business mailing address

12811 Q ST
OMAHA NE
68137-3211
US

V. Phone/Fax

Practice location:
  • Phone: 402-230-5861
  • Fax: 531-200-5808
Mailing address:
  • Phone: 402-230-5861
  • Fax: 531-200-5808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-528241
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: