Healthcare Provider Details

I. General information

NPI: 1396554259
Provider Name (Legal Business Name): MACKENZIE J HENNESSY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2025
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1423 WINYAH ST
GEORGETOWN SC
29440-4730
US

IV. Provider business mailing address

1423 WINYAH ST
GEORGETOWN SC
29440-4730
US

V. Phone/Fax

Practice location:
  • Phone: 843-546-6081
  • Fax: 843-527-1697
Mailing address:
  • Phone: 843-546-6081
  • Fax: 843-527-1697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: