Healthcare Provider Details

I. General information

NPI: 1891010823
Provider Name (Legal Business Name): KEVIN R MCKENZIE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2010
Last Update Date: 11/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 W 33RD ST
EDMOND OK
73013-3819
US

IV. Provider business mailing address

524 SW 160 ST
OKLAHOMA OK
73170
US

V. Phone/Fax

Practice location:
  • Phone: 405-216-5608
  • Fax:
Mailing address:
  • Phone: 405-824-5589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: