=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649089947
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MACKINZY MENTAL HEALTH CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2025
-----------------------------------------------------
Last Update Date | 01/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 31080 UNION CITY BLVD STE 102
-----------------------------------------------------
City | UNION CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94587-4212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-938-2289
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31080 UNION CITY BLVD STE 102
-----------------------------------------------------
City | UNION CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94587-4212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-938-2289
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGY
-----------------------------------------------------
Name | SOZANA GBRAAEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 510-938-2289
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------