MEDICARE: MACKENZIE GRAY

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	106S00000X	Behavior Technician	RBT-20135934	IN
2	103K00000X	Behavior Analyst	1-23-64632	IN

General Provider Information

NPI Number	:	1942965108
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MACKENZIE GRAY

Provider Business Mailing Address
First Line	:	315 WASHINGTON ST
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47201-6743
Country	:	US
Telephone Number	:	812-413-9321
Fax Number	:	812-413-9323

Provider Business Practice Location Address
First Line	:	2600 SANDCREST BLVD
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47203-3053
Country	:	US
Telephone Number	:	812-413-9321
Fax Number	:	812-413-9323

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

Provider Enumeration Date	:	11/03/2021
Last Update Date	:	03/14/2023

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Directions to “ MACKENZIE GRAY ” Practice Location

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