Provider Demographics
NPI:1346429693
Name:MACKENZIE-LAXAGUE, JUDY LUCILE (SPEECH PATHOLOGIST)
Entity Type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:LUCILE
Last Name:MACKENZIE-LAXAGUE
Suffix:
Gender:F
Credentials:SPEECH PATHOLOGIST
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:12 ABIGAIL WAY
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-8246
Mailing Address - Country:US
Mailing Address - Phone:207-885-5791
Mailing Address - Fax:207-885-5791
Practice Address - Street 1:65 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2617
Practice Address - Country:US
Practice Address - Phone:207-615-5791
Practice Address - Fax:207-885-5791
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-02
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESPA 723235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist