Provider Demographics
NPI:1871289314
Name:VANVACTOR, MCKENZIE RAYE (OTR/L)
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:RAYE
Last Name:VANVACTOR
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 SIVLEY RD APT 205
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42240-7979
Mailing Address - Country:US
Mailing Address - Phone:678-591-9154
Mailing Address - Fax:
Practice Address - Street 1:851 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5257
Practice Address - Country:US
Practice Address - Phone:931-542-2168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-17
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7057225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist