Provider Demographics
NPI:1306371570
Name:ODELL, MACKENZIE JOAN (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MACKENZIE
Middle Name:JOAN
Last Name:ODELL
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 1:30980 FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:MI
Mailing Address - Zip Code:48025-1493
Mailing Address - Country:US
Mailing Address - Phone:248-763-6694
Mailing Address - Fax:
Practice Address - Street 1:30980 FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:MI
Practice Address - Zip Code:48025-1493
Practice Address - Country:US
Practice Address - Phone:248-763-6694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-26
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101004243235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist