Provider Demographics
NPI:1679821490
Name:FORMAN, MACKENZIE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:FORMAN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5326 GLENMORGAN LN
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-8884
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5509 POINT LAKE CT
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:27540-9349
Practice Address - Country:US
Practice Address - Phone:919-656-2901
Practice Address - Fax:888-893-4354
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9405235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist