Provider Demographics
NPI:1235730094
Name:FRITZ, MACKENZIE LYN (CF-SLP)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:LYN
Last Name:FRITZ
Suffix:
Gender:F
Credentials:CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 E POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:NM
Mailing Address - Zip Code:88030-4807
Mailing Address - Country:US
Mailing Address - Phone:575-546-5951
Mailing Address - Fax:575-546-5994
Practice Address - Street 1:1060 CERRILLOS RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-1650
Practice Address - Country:US
Practice Address - Phone:505-476-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCF7179235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist