MEDICARE: MCKENZEE CAMPBELL

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	103K00000X	Behavior Analyst	1-21-52132	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1437668001
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MCKENZEE CAMPBELL

Provider Business Mailing Address
First Line	:	PO BOX 631278
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45263-1278
Country	:	US
Telephone Number	:	800-356-4049
Fax Number	:	941-485-0519

Provider Business Practice Location Address
First Line	:	6196 LAKE GRAY BLVD STE 116
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32244-5867
Country	:	US
Telephone Number	:	800-356-4049
Fax Number	:	941-485-0519

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

Provider Enumeration Date	:	09/26/2017
Last Update Date	:	08/11/2021

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1134676711 — KATELYN LUKSHA
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Directions to “ MCKENZEE CAMPBELL ” Practice Location

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