MEDICARE: MAYKENZIE INEZ SOUTH

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	103K00000X
2	106E00000X	Assistant Behavior Analyst	106E00000X
3	106S00000X	Behavior Technician	106S00000X	CA

General Provider Information

NPI Number	:	1710812763
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAYKENZIE INEZ SOUTH

Provider Business Mailing Address
First Line	:	11624 TYLER FOOTE RD
Second Line	:
City	:	NEVADA CITY
State	:	CA
Zip	:	95959-9310
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11624 TYLER FOOTE RD
Second Line	:
City	:	NEVADA CITY
State	:	CA
Zip	:	95959-9310
Country	:	US
Telephone Number	:	530-615-1180
Fax Number	:

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

Provider Enumeration Date	:	06/12/2026
Last Update Date	:	06/12/2026

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Directions to “ MAYKENZIE INEZ SOUTH ” Practice Location

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