Provider Demographics
NPI:1679304372
Name:GRUENERT, MACKENZI
Entity type:Individual
Prefix:
First Name:MACKENZI
Middle Name:
Last Name:GRUENERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7616 ORCHARD VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46217-2910
Mailing Address - Country:US
Mailing Address - Phone:812-239-1549
Mailing Address - Fax:
Practice Address - Street 1:1634 W SMITH VALLEY RD APT A
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-1550
Practice Address - Country:US
Practice Address - Phone:317-210-3737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health