Provider Demographics
NPI:1497580740
Name:DALLENBACH STEVENSON, MACKENZIE LEE (LCSW)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:LEE
Last Name:DALLENBACH STEVENSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:LEE
Other - Last Name:DALLENBACH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:4001 HYDE PARK AVE APT 10A
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-7120
Mailing Address - Country:US
Mailing Address - Phone:319-240-3689
Mailing Address - Fax:
Practice Address - Street 1:19 E WALNUT ST STE D
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-4505
Practice Address - Country:US
Practice Address - Phone:573-442-7232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20240295821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical