Provider Demographics
NPI:1871052936
Name:GANE, MACKENZIE
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:GANE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:
Other - Last Name:CERDA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:18685 MAIN ST STE 101-459
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-1723
Mailing Address - Country:US
Mailing Address - Phone:714-697-1907
Mailing Address - Fax:
Practice Address - Street 1:3056 MILES JOHNSON PKWY
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:TN
Practice Address - Zip Code:37174-4564
Practice Address - Country:US
Practice Address - Phone:877-407-3422
Practice Address - Fax:877-407-4329
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician