Provider Demographics
NPI:1558983726
Name:GROSS, MACKENZIE RAE (MS, CF-SLP)
Entity Type:Individual
Prefix:MS
First Name:MACKENZIE
Middle Name:RAE
Last Name:GROSS
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8441 W 131ST PL APT 633
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66213-5116
Mailing Address - Country:US
Mailing Address - Phone:817-881-2811
Mailing Address - Fax:
Practice Address - Street 1:427 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:KS
Practice Address - Zip Code:66030-1183
Practice Address - Country:US
Practice Address - Phone:913-856-8747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS3553235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS23Medicaid