MEDICARE: MACKENZIE RAY

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	106S00000X	Behavior Technician	RBT-17-35448	CA

General Provider Information

NPI Number	:	1194074294
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MACKENZIE RAY

Provider Business Mailing Address
First Line	:	214 ESTATES DR STE A
Second Line	:
City	:	ROSEVILLE
State	:	CA
Zip	:	95678-2353
Country	:	US
Telephone Number	:	916-749-4646
Fax Number	:	916-749-4520

Provider Business Practice Location Address
First Line	:	214 ESTATES DR STE A
Second Line	:
City	:	ROSEVILLE
State	:	CA
Zip	:	95678-2353
Country	:	US
Telephone Number	:	916-749-4646
Fax Number	:	916-749-4520

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

Provider Enumeration Date	:	09/05/2012
Last Update Date	:	03/19/2018

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Directions to “ MACKENZIE RAY ” Practice Location

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