Provider Demographics
NPI:1902350077
Name:MACKENZIE, NORMAN III (SUDCC-II)
Entity Type:Individual
Prefix:MR
First Name:NORMAN
Middle Name:
Last Name:MACKENZIE
Suffix:III
Gender:M
Credentials:SUDCC-II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5473 KEARNY VILLA RD STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1142
Mailing Address - Country:US
Mailing Address - Phone:619-500-8212
Mailing Address - Fax:
Practice Address - Street 1:5473 KEARNY VILLA RD STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1160
Practice Address - Country:US
Practice Address - Phone:619-500-8212
Practice Address - Fax:619-881-8079
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-06
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA10042101YA0400X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)