Provider Demographics
NPI:1164615753
Name:THOMAS, MACKENZIE BROADBENT (AUD)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:BROADBENT
Last Name:THOMAS
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 CREEKSIDE PARK RD STE 107
Mailing Address - Street 2:
Mailing Address - City:SPRING BRANCH
Mailing Address - State:TX
Mailing Address - Zip Code:78070-6226
Mailing Address - Country:US
Mailing Address - Phone:830-438-7766
Mailing Address - Fax:830-468-6110
Practice Address - Street 1:172 CREEKSIDE PARK RD STE 107
Practice Address - Street 2:
Practice Address - City:SPRING BRANCH
Practice Address - State:TX
Practice Address - Zip Code:78070-6226
Practice Address - Country:US
Practice Address - Phone:830-438-7766
Practice Address - Fax:830-438-6110
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-27
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX51599231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist