Provider Demographics
NPI:1326812652
Name:GREEN, MACKENZIE LADANE
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:LADANE
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 WALNUT RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-8878
Mailing Address - Country:US
Mailing Address - Phone:417-294-4781
Mailing Address - Fax:
Practice Address - Street 1:140 WALNUT RIDGE RD
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-8878
Practice Address - Country:US
Practice Address - Phone:417-294-4781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20230382432355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant