MEDICARE: MACKENZIE GRAE THACKER DPT

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	225100000X	Physical Therapist	12231	SC

General Provider Information

NPI Number	:	1235994161
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MACKENZIE GRAE THACKER DPT

Provider Business Mailing Address
First Line	:	PO BOX 2397
Second Line	:
City	:	PAWLEYS ISLAND
State	:	SC
Zip	:	29585-2397
Country	:	US
Telephone Number	:	843-235-0200
Fax Number	:	843-235-0242

Provider Business Practice Location Address
First Line	:	38 BUSINESS CENTER DRIVE
Second Line	:
City	:	PAWLEYS ISLAND
State	:	SC
Zip	:	29585
Country	:	US
Telephone Number	:	843-235-0200
Fax Number	:

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

Provider Enumeration Date	:	02/20/2024
Last Update Date	:	01/12/2026

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Directions to “ MACKENZIE GRAE THACKER DPT” Practice Location

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