Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 13279 | WI |
Y | 1041C0700X | Clinical Social Worker | 1239-123 | WI |
NPI | 1013010024 |
---|---|
Provider Name | Mrs. Amy Sue Mckenzie |
First Address | Cleveland, WI 53015-1413 |
Second Address | Cleveland, WI 53015-1413 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/09/2006 |
Last Update Date | 28/02/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
42194800 | (05) | WI |