MEDICARE: AIDZA Y. MCKENZIE PH.D.

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	103TC0700X	Clinical Psychologist	8152	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	W10610	OTHER	MA	BLUE CROSS PROVIDER NUMBE

General Provider Information

NPI Number	:	1942359187
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AIDZA Y. MCKENZIE PH.D.

Provider Business Mailing Address
First Line	:	108 RUSSELL ST
Second Line	:
City	:	HADLEY
State	:	MA
Zip	:	01035-9595
Country	:	US
Telephone Number	:	413-387-0075
Fax Number	:	413-387-0074

Provider Business Practice Location Address
First Line	:	108 RUSSELL ST
Second Line	:
City	:	HADLEY
State	:	MA
Zip	:	01035-9595
Country	:	US
Telephone Number	:	413-387-0075
Fax Number	:	413-387-0074

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

Provider Enumeration Date	:	01/09/2007
Last Update Date	:	03/09/2009

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