Basic Information
| Provider Information | |||||||||
| NPI: | 1134635774 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKENZIE | ||||||||
| FirstName: | MADISON | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | CSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 615 ELSINORE PL STE 200 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452021459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138347063 | ||||||||
| FaxNumber: | 5138731567 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 LINVILLE DR STE 102 | ||||||||
| Address2: | |||||||||
| City: | PARIS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403612165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138347063 | ||||||||
| FaxNumber: | 5138731567 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2017 | ||||||||
| LastUpdateDate: | 07/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 252947 | KY | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 1790731081 | 05 | KY | MEDICAID | 7100721790 | 05 | KY | MEDICAID |