Healthcare Provider Details

I. General information

NPI: 1821918699
Provider Name (Legal Business Name): MACKENZIE RYAN WILLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87 PARK AVE
OLD BRIDGE NJ
08857-1223
US

IV. Provider business mailing address

87 PARK AVE
OLD BRIDGE NJ
08857-1223
US

V. Phone/Fax

Practice location:
  • Phone: 732-763-9467
  • Fax:
Mailing address:
  • Phone: 732-763-9467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number46TR01295200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: