Basic Information
| Provider Information | |||||||||
| NPI: | 1457554909 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACKENZIE | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | EUGENE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2401 DEMERS AVE | ||||||||
| Address2: | |||||||||
| City: | GRAND FORKS | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017801891 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1375 S COLUMBIA RD - ALTRU PERFORMANCE CENTER | ||||||||
| Address2: | |||||||||
| City: | GRAND FORKS | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017805000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2007 | ||||||||
| LastUpdateDate: | 07/02/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 940 | ND | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.