Provider Demographics
NPI:1942662119
Name:MILLER, MACKENZIE ROSALYN
Entity type:Individual
Prefix:MISS
First Name:MACKENZIE
Middle Name:ROSALYN
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7690 NEW MARKET CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-1976
Mailing Address - Country:US
Mailing Address - Phone:614-602-6473
Mailing Address - Fax:
Practice Address - Street 1:514 JACKSON ST
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-2737
Practice Address - Country:US
Practice Address - Phone:614-602-6473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-25
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHTH788947171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator