Provider Demographics
NPI:1053034389
Name:KEITH, MCKENZIE MICHELLE (SUDP)
Entity type:Individual
Prefix:MRS
First Name:MCKENZIE
Middle Name:MICHELLE
Last Name:KEITH
Suffix:
Gender:F
Credentials:SUDP
Other - Prefix:MRS
Other - First Name:MCKENZIE
Other - Middle Name:MICHELLE
Other - Last Name:STURM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SUDP
Mailing Address - Street 1:5712 N LOMA DR
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205-7269
Mailing Address - Country:US
Mailing Address - Phone:928-499-5954
Mailing Address - Fax:
Practice Address - Street 1:5712 N LOMA DR
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-7269
Practice Address - Country:US
Practice Address - Phone:928-499-5954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-21
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP61413299101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACP61413299OtherDOH