Healthcare Provider Details

I. General information

NPI: 1487305769
Provider Name (Legal Business Name): MCKENZIE GAYLE SHINABERRY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2022
Last Update Date: 01/18/2022
Certification Date: 01/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 SIMPSON AVE STE 101
ABERDEEN WA
98520-4333
US

IV. Provider business mailing address

PO BOX 1847
LONGVIEW WA
98632-8140
US

V. Phone/Fax

Practice location:
  • Phone: 360-612-0012
  • Fax: 360-532-0670
Mailing address:
  • Phone: 360-423-0203
  • Fax: 360-577-0187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCG61263500
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: