Provider Demographics
NPI:1144931262
Name:EGGERS, MACKENZIE ROSE
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:ROSE
Last Name:EGGERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3408 PRIMROSE LN
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-3217
Mailing Address - Country:US
Mailing Address - Phone:231-675-0240
Mailing Address - Fax:
Practice Address - Street 1:350 N MAIN ST STE 220
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:MI
Practice Address - Zip Code:48118-1635
Practice Address - Country:US
Practice Address - Phone:517-884-1882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-09
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI68511165591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician