Provider Demographics
NPI:1710616974
Name:BAXTER, MCKENNA L (SLPA)
Entity Type:Individual
Prefix:MS
First Name:MCKENNA
Middle Name:L
Last Name:BAXTER
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 W LEROUX ST
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86303-4124
Mailing Address - Country:US
Mailing Address - Phone:928-713-8865
Mailing Address - Fax:
Practice Address - Street 1:812 VALLEY ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-1826
Practice Address - Country:US
Practice Address - Phone:928-445-1309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-05
Last Update Date:2022-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA134582355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant