Provider Demographics
NPI:1790656304
Name:MOAK, MACKENZIE
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:MOAK
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 1:1600 BIRCH LN
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95618-1450
Mailing Address - Country:US
Mailing Address - Phone:530-757-5395
Mailing Address - Fax:
Practice Address - Street 1:1600 BIRCH LN
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95618-1450
Practice Address - Country:US
Practice Address - Phone:530-757-5395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-16
Last Update Date:2025-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA250140594101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool