Provider Demographics
NPI:1730511007
Name:LONG, MCKENZIE DUGAN (PT)
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:DUGAN
Last Name:LONG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10837
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85318-0837
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5620 W THUNDERBIRD RD
Practice Address - Street 2:B1
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4636
Practice Address - Country:US
Practice Address - Phone:602-938-2422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-08
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10460225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist