Basic Information
Provider Information | |||||||||
NPI: | 1548218555 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCKENZIE | ||||||||
FirstName: | DEAN | ||||||||
MiddleName: | WM | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 188 | ||||||||
Address2: |   | ||||||||
City: | MARANA | ||||||||
State: | AZ | ||||||||
PostalCode: | 856530188 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5206824111 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 13395 N MARANA MAIN ST | ||||||||
Address2: |   | ||||||||
City: | MARANA | ||||||||
State: | AZ | ||||||||
PostalCode: | 856537008 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5206821091 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2006 | ||||||||
LastUpdateDate: | 01/13/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/13/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 042.0012187 | VT | N |   | Behavioral Health & Social Service Providers | Psychologist |   | 207RA0401X | 042.0012187 | VT | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine | 2084A0401X | 37977 | AZ | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine |
ID Information
ID | Type | State | Issuer | Description | 372326 | 05 | AZ |   | MEDICAID | 1019195 | 05 | VT |   | MEDICAID | 04391255 | 05 | NY |   | MEDICAID | 000606339A | 05 | GA |   | MEDICAID |