Provider Demographics
NPI:1265031223
Name:MACKENZIE, CALLIE (LCSW)
Entity type:Individual
Prefix:
First Name:CALLIE
Middle Name:
Last Name:MACKENZIE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 MISTYHAVEN PL
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77381-4050
Mailing Address - Country:US
Mailing Address - Phone:571-432-7400
Mailing Address - Fax:
Practice Address - Street 1:11 MISTYHAVEN PL
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77381-4050
Practice Address - Country:US
Practice Address - Phone:571-432-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-21
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA30721041C0700X
TX1033721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX417248801Medicaid