MEDICARE: MCKENZIE LAINE WILSON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	C011603	NC

General Provider Information

NPI Number	:	1144671991
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MCKENZIE LAINE WILSON LCSW

Provider Business Mailing Address
First Line	:	4030 WINBURN LN
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27106-2938
Country	:	US
Telephone Number	:	336-529-2557
Fax Number	:

Provider Business Practice Location Address
First Line	:	4030 WINBURN LN
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27106-2938
Country	:	US
Telephone Number	:	336-529-2557
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2016
Last Update Date	:	05/20/2026

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