Provider Demographics
NPI:1568084846
Name:KIST, MCKENZIE (MHS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:
Last Name:KIST
Suffix:
Gender:F
Credentials:MHS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6450 BLACK RIDGE VW APT 202
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80924-4455
Mailing Address - Country:US
Mailing Address - Phone:479-747-8841
Mailing Address - Fax:
Practice Address - Street 1:6190 BARNES RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80922-2600
Practice Address - Country:US
Practice Address - Phone:719-247-1511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-10
Last Update Date:2020-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSLP.0000520235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist