Provider Demographics
NPI:1063812527
Name:CAROLE MACKENZIE LCSW
Entity type:Organization
Organization Name:CAROLE MACKENZIE LCSW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:PROF
Authorized Official - First Name:CAROLE
Authorized Official - Middle Name:HOLABIRD
Authorized Official - Last Name:MACKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:860-231-7373
Mailing Address - Street 1:674 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-4288
Mailing Address - Country:US
Mailing Address - Phone:860-231-7373
Mailing Address - Fax:860-233-5736
Practice Address - Street 1:674 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-4288
Practice Address - Country:US
Practice Address - Phone:860-231-7373
Practice Address - Fax:860-233-5736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-02
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002083261QM0850X, 1041C0700X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty