Provider Demographics
NPI:1730213513
Name:MCKENZIE, MARJORIE GENE RAE (MS OTRL)
Entity type:Individual
Prefix:
First Name:MARJORIE
Middle Name:GENE RAE
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:MS OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3075 QUAY ROAD 61
Mailing Address - Street 2:
Mailing Address - City:TUCUMCARI
Mailing Address - State:NM
Mailing Address - Zip Code:88401-9458
Mailing Address - Country:US
Mailing Address - Phone:505-576-2776
Mailing Address - Fax:
Practice Address - Street 1:3075 QUAY ROAD 61
Practice Address - Street 2:
Practice Address - City:TUCUMCARI
Practice Address - State:NM
Practice Address - Zip Code:88401-9458
Practice Address - Country:US
Practice Address - Phone:505-576-2776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM000645225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000K0335Medicaid