Provider Demographics
NPI:1326470261
Name:MCCOLLAM, MACKENZIE M (SLP, MS)
Entity Type:Individual
Prefix:MRS
First Name:MACKENZIE
Middle Name:M
Last Name:MCCOLLAM
Suffix:
Gender:F
Credentials:SLP, MS
Other - Prefix:MS
Other - First Name:MACKENZIE
Other - Middle Name:M
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22512 E HEROY AVE
Mailing Address - Street 2:
Mailing Address - City:OTIS ORCHARDS
Mailing Address - State:WA
Mailing Address - Zip Code:99027-9316
Mailing Address - Country:US
Mailing Address - Phone:509-954-5876
Mailing Address - Fax:
Practice Address - Street 1:2510 N PINES RD STE 3
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-7636
Practice Address - Country:US
Practice Address - Phone:509-315-5711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-02
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASI 60402274235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist