Provider Demographics
NPI:1518237643
Name:STAUFFER, MACKENZIE JOAN (CCC/SLP)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:JOAN
Last Name:STAUFFER
Suffix:
Gender:F
Credentials:CCC/SLP
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:JOAN
Other - Last Name:ACKLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP-CFY
Mailing Address - Street 1:1410 14TH ST
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75074-6302
Mailing Address - Country:US
Mailing Address - Phone:972-424-0148
Mailing Address - Fax:972-422-5275
Practice Address - Street 1:1410 14TH ST
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074-6302
Practice Address - Country:US
Practice Address - Phone:972-424-0148
Practice Address - Fax:972-422-5275
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106312235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist