Provider Demographics
NPI:1417424813
Name:RODDY, MACKENZIE VERNAY (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:VERNAY
Last Name:RODDY
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3521 JOSIE AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808-2910
Mailing Address - Country:US
Mailing Address - Phone:714-401-8836
Mailing Address - Fax:
Practice Address - Street 1:3620 LONG BEACH BLVD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-4022
Practice Address - Country:US
Practice Address - Phone:714-401-8836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP20543235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist