Provider Demographics
NPI:1104374602
Name:TALLCOTT, MACKENZI JO (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MACKENZI
Middle Name:JO
Last Name:TALLCOTT
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 1:2631 KEN RAY DR
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-6117
Mailing Address - Country:US
Mailing Address - Phone:217-209-1748
Mailing Address - Fax:
Practice Address - Street 1:2631 KEN RAY DR
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-6117
Practice Address - Country:US
Practice Address - Phone:217-209-1748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-14
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146013992235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist