Healthcare Provider Details

I. General information

NPI: 1134959554
Provider Name (Legal Business Name): MACKENZIE MARIE ST. JOHN MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2024
Last Update Date: 08/02/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 ORPHANAGE ROAD
LITTLESTOWN PA
17340-9329
US

IV. Provider business mailing address

815 ORPHANAGE ROAD
LITTLESTOWN PA
17340-9329
US

V. Phone/Fax

Practice location:
  • Phone: 717-359-7148
  • Fax: 717-359-2600
Mailing address:
  • Phone: 717-359-7148
  • Fax: 717-359-2600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: