Provider Demographics
NPI:1548749609
Name:WYSONG, MACKENZIE (SLP)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:WYSONG
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:494 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-1470
Mailing Address - Country:US
Mailing Address - Phone:740-369-3650
Mailing Address - Fax:
Practice Address - Street 1:494 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-1470
Practice Address - Country:US
Practice Address - Phone:740-369-3650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-09
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0364590Medicaid