Provider Demographics
NPI:1013403351
Name:MCKENZIE, VIVA T (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:VIVA
Middle Name:T
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 COMMED BLVD
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8321
Mailing Address - Country:US
Mailing Address - Phone:575-518-4088
Mailing Address - Fax:
Practice Address - Street 1:820 COMMED BLVD
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763
Practice Address - Country:US
Practice Address - Phone:575-518-4088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-10
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA12599235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE