Provider Demographics
NPI:1659095636
Name:KIMMONS, MACKENZIE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:KIMMONS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2614 BRIARBROOK LN
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75040-3922
Mailing Address - Country:US
Mailing Address - Phone:214-986-7810
Mailing Address - Fax:
Practice Address - Street 1:3131 MARS DR
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75040-3852
Practice Address - Country:US
Practice Address - Phone:972-675-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117704235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist