Basic Information
| Provider Information | |||||||||
| NPI: | 1902467822 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RICKERT | ||||||||
| FirstName: | MACKENZIE | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | MS, OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 ADAMS ST APT 1 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021555206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4012560644 | ||||||||
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| Practice Location | |||||||||
| Address1: | 49 WALNUT PARK | ||||||||
| Address2: | BUILDING 3 | ||||||||
| City: | WELLESLEY HILLS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7812390100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2019 | ||||||||
| LastUpdateDate: | 06/21/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 13193 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.