Basic Information
| Provider Information | |||||||||
| NPI: | 1760598205 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKENZIE | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | ANDREW | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 632 WASHINGTON ST | ||||||||
| Address2: | UNIT E6 | ||||||||
| City: | BRAINTREE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021845727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818491250 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 151 MYSTIC AVE | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021554632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813961199 | ||||||||
| FaxNumber: | 7813961439 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 3389 | MA | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.