Provider Demographics
NPI:1578173456
Name:MCBRIDE, MACKENZIE (MS, CF-SLP)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:MCBRIDE
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 1:207 W GEORGIA AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-3024
Mailing Address - Country:US
Mailing Address - Phone:208-467-1069
Mailing Address - Fax:
Practice Address - Street 1:207 W GEORGIA AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-3024
Practice Address - Country:US
Practice Address - Phone:208-467-1069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDTSLP-4408Medicaid