Provider Demographics
NPI:1861993800
Name:MCKENZIE, BREANN LEE
Entity type:Individual
Prefix:
First Name:BREANN
Middle Name:LEE
Last Name:MCKENZIE
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 1:915 HIGHLAND POINTE DR STE 250
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-5421
Mailing Address - Country:US
Mailing Address - Phone:310-714-7698
Mailing Address - Fax:
Practice Address - Street 1:1050 FULTON AVE STE 235
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825
Practice Address - Country:US
Practice Address - Phone:916-974-2599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-26
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3747A0650X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Single Specialty