Provider Demographics
NPI:1245128081
Name:SMITH, MACKENZIE LEE
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:LEE
Other - Last Name:HERNANDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11851 SAULSBURY ST
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-2808
Mailing Address - Country:US
Mailing Address - Phone:303-404-0123
Mailing Address - Fax:
Practice Address - Street 1:11851 SAULSBURY ST
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-2808
Practice Address - Country:US
Practice Address - Phone:303-404-0123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-27
Last Update Date:2025-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-25-447869103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst