MEDICARE: MS. TRACEY LEE MACKENZIE BST

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1912207689
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TRACEY LEE MACKENZIE BST

Provider Business Mailing Address
First Line	:	4224 ARCATA WAY STE A
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89030-3381
Country	:	US
Telephone Number	:	702-489-6318
Fax Number	:

Provider Business Practice Location Address
First Line	:	4224 ARCATA WAY STE A
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89030-3381
Country	:	US
Telephone Number	:	702-489-6318
Fax Number	:

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

Provider Enumeration Date	:	10/28/2010
Last Update Date	:	11/01/2010

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