Provider Demographics
NPI:1629830088
Name:HICKEY, MACKENZIE ALEXIS MARTA
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:ALEXIS MARTA
Last Name:HICKEY
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 1:1103 CANYON DR
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-1874
Mailing Address - Country:US
Mailing Address - Phone:303-387-5000
Mailing Address - Fax:
Practice Address - Street 1:1103 CANYON DR
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-1874
Practice Address - Country:US
Practice Address - Phone:303-387-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO24443747235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist