Provider Demographics
NPI:1518222678
Name:MACK, KERRY (MS, SLP)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:MS, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 W NEWPORT BEACH DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-6742
Mailing Address - Country:US
Mailing Address - Phone:480-216-7433
Mailing Address - Fax:
Practice Address - Street 1:10049 E DYNAMITE BLVD STE 110
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85262-3694
Practice Address - Country:US
Practice Address - Phone:480-419-0848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-05
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP7367235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist