Healthcare Provider Details

I. General information

NPI: 1568030617
Provider Name (Legal Business Name): MACKENZIE CONLEY CT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2021
Last Update Date: 01/20/2022
Certification Date: 01/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 E WILSON BRIDGE RD STE A5
WORTHINGTON OH
43085-2358
US

IV. Provider business mailing address

71 E WILSON BRIDGE RD STE A5
WORTHINGTON OH
43085-2358
US

V. Phone/Fax

Practice location:
  • Phone: 614-547-9233
  • Fax:
Mailing address:
  • Phone: 614-547-9233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.2203944
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberC.2002765-TRNE
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: