Provider Demographics
NPI:1710341805
Name:BAILEY, MACKENZY (MA CCC SLP)
Entity Type:Individual
Prefix:
First Name:MACKENZY
Middle Name:
Last Name:BAILEY
Suffix:
Gender:F
Credentials:MA CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 BURTON MESA BLVD
Mailing Address - Street 2:STE B
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-1400
Mailing Address - Country:US
Mailing Address - Phone:805-733-4542
Mailing Address - Fax:805-733-4392
Practice Address - Street 1:191 BURTON MESA BLVD
Practice Address - Street 2:STE B
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-1400
Practice Address - Country:US
Practice Address - Phone:805-733-4542
Practice Address - Fax:805-733-4392
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-05
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP23436235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSP00390Medicaid