Provider Demographics
NPI:1063860047
Name:WOOD, MACKENZIE (CCC, SLP)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:WOOD
Suffix:
Gender:F
Credentials:CCC, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6458 CITY WEST PKWY
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-3245
Mailing Address - Country:US
Mailing Address - Phone:952-767-6977
Mailing Address - Fax:
Practice Address - Street 1:6458 CITY WEST PKWY
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-3245
Practice Address - Country:US
Practice Address - Phone:952-767-6977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9805235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist