Provider Demographics
NPI:1326713694
Name:VERDEGAN, MACKINZIE LEE (COTA)
Entity type:Individual
Prefix:
First Name:MACKINZIE
Middle Name:LEE
Last Name:VERDEGAN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:MACKINZIE
Other - Middle Name:LEE
Other - Last Name:FALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2217 DUNCAN ROAD
Mailing Address - Street 2:
Mailing Address - City:BLOOMER
Mailing Address - State:WI
Mailing Address - Zip Code:54724
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2217 DUNCAN ROAD
Practice Address - Street 2:
Practice Address - City:BLOOMER
Practice Address - State:WI
Practice Address - Zip Code:54724
Practice Address - Country:US
Practice Address - Phone:715-641-0510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-10
Last Update Date:2025-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5795-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant