Provider Demographics
NPI:1629548714
Name:SMITH, MACKENZIE ANNE
Entity Type:Individual
Prefix:MISS
First Name:MACKENZIE
Middle Name:ANNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2053 N SHEFFIELD AVE APT 4F
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-7424
Mailing Address - Country:US
Mailing Address - Phone:815-245-1435
Mailing Address - Fax:
Practice Address - Street 1:1765 N ELSTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-1501
Practice Address - Country:US
Practice Address - Phone:312-399-0370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-30
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242006277235Z00000X
IL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist