Provider Demographics
NPI:1366291171
Name:GRIFFIN, MACKENZIE ROSE (OTR/L)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:ROSE
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3621 PARK BLVD APT H
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-4500
Mailing Address - Country:US
Mailing Address - Phone:949-632-0280
Mailing Address - Fax:
Practice Address - Street 1:3621 PARK BLVD APT H
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-4500
Practice Address - Country:US
Practice Address - Phone:949-632-0280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-14
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26126225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty