=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700127057
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CELINA MAE MCKENZIE BCTMB, CR, CIMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2013
-----------------------------------------------------
Last Update Date | 08/29/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 315 WALNUT ST
-----------------------------------------------------
City | MONTICELLO
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55362-8839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-702-1338
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8240 173RD AVE SE
-----------------------------------------------------
City | BECKER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55308-5101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-702-1338
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 560863-08
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------