=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992404255
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAKENZY MARY MARGARET THOMAS RBT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2023
-----------------------------------------------------
Last Update Date | 03/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4005 SAWNEY DR
-----------------------------------------------------
City | GREENBRIER
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37073-5916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-483-6815
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4005 SAWNEY DR
-----------------------------------------------------
City | GREENBRIER
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37073-5916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-483-6815
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | RBT-23-260286
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------