Provider Demographics
NPI:1326919002
Name:SOVERCOOL, MAKENZIE DIANA
Entity type:Individual
Prefix:
First Name:MAKENZIE
Middle Name:DIANA
Last Name:SOVERCOOL
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 1:324 N YORK ST
Mailing Address - Street 2:
Mailing Address - City:BUSHNELL
Mailing Address - State:FL
Mailing Address - Zip Code:33513-5304
Mailing Address - Country:US
Mailing Address - Phone:352-801-4287
Mailing Address - Fax:
Practice Address - Street 1:13780 SE 100TH AVE
Practice Address - Street 2:
Practice Address - City:BELLEVIEW
Practice Address - State:FL
Practice Address - Zip Code:34420-6955
Practice Address - Country:US
Practice Address - Phone:352-789-0713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-15
Last Update Date:2025-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL33587225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant