Healthcare Provider Details

I. General information

NPI: 1669718961
Provider Name (Legal Business Name): MACKENZIE ANSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2012
Last Update Date: 12/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 FAMILY PRACTICE DR
KINGSTON NY
12401-6449
US

IV. Provider business mailing address

279 MAIN ST SUITE 204
NEW PALTZ NY
12561-1623
US

V. Phone/Fax

Practice location:
  • Phone: 845-339-9055
  • Fax: 845-339-2310
Mailing address:
  • Phone: 845-255-3046
  • Fax: 845-255-0236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number087547
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: