Provider Demographics
NPI:1508422247
Name:MANN, MCKENZIE ANNETTE
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:ANNETTE
Last Name:MANN
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 1:1156 E 61ST ST APT 611
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-2664
Mailing Address - Country:US
Mailing Address - Phone:626-222-4641
Mailing Address - Fax:626-222-4641
Practice Address - Street 1:11053 S MILLARD AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-3327
Practice Address - Country:US
Practice Address - Phone:773-253-9856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-17
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242007106235Z00000X
IL146017429235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1396085718Medicaid