1427506419 NPI number — MCKENZIE RAE BEHRENDT OTR/L, OTD

Table of content: MCKENZIE RAE BEHRENDT OTR/L, OTD (NPI 1427506419)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427506419 NPI number — MCKENZIE RAE BEHRENDT OTR/L, OTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEHRENDT
Provider First Name:
MCKENZIE
Provider Middle Name:
RAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR/L, OTD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WIESE
Provider Other First Name:
MCKENZIE
Provider Other Middle Name:
RAE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR/L, OTD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1427506419
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/06/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25740 BUCKEYE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RAVENNA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68869-3280
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
615 W 39TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KEARNEY
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68845-8045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-698-2820
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/19/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  1978 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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