Provider Demographics
NPI:1740099290
Name:BROWN, MACKENZIE LAUREL
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:LAUREL
Last Name:BROWN
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 1:473 WOODBURY CT SE
Mailing Address - Street 2:
Mailing Address - City:BOLIVIA
Mailing Address - State:NC
Mailing Address - Zip Code:28422-8685
Mailing Address - Country:US
Mailing Address - Phone:910-612-1002
Mailing Address - Fax:910-755-5586
Practice Address - Street 1:4501 MAIN ST STE 5
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-4585
Practice Address - Country:US
Practice Address - Phone:910-612-1002
Practice Address - Fax:910-755-5865
Is Sole Proprietor?:No
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30003085235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist