Basic Information
| Provider Information | |||||||||
| NPI: | 1467785170 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GANCSOS | ||||||||
| FirstName: | MACKENZIE | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | BS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2708 NE 14TH ST APT 5 | ||||||||
| Address2: | |||||||||
| City: | POMPANO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330623564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9546037885 | ||||||||
| FaxNumber: | 9543420273 | ||||||||
| Practice Location | |||||||||
| Address1: | 2708 NE 14TH ST APT 5 | ||||||||
| Address2: | |||||||||
| City: | POMPANO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330623564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9546037885 | ||||||||
| FaxNumber: | 9543420273 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2009 | ||||||||
| LastUpdateDate: | 09/13/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 222Q00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
No ID Information.