MEDICARE: DEVAN MCKENZIE

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	101Y00000X	Counselor	LAC-15836	AZ
2	101YP2500X	Professional Counselor	LPC-18165	AZ

General Provider Information

NPI Number	:	1811424757
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEVAN MCKENZIE

Provider Business Mailing Address
First Line	:	16180 W IRONWOOD ST
Second Line	:
City	:	SURPRISE
State	:	AZ
Zip	:	85374-5831
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9014 S CENTRAL AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85042-8304
Country	:	US
Telephone Number	:	602-230-7373
Fax Number	:	602-441-5839

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

Provider Enumeration Date	:	05/22/2017
Last Update Date	:	09/11/2020

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Directions to “ DEVAN MCKENZIE ” Practice Location

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