Provider Demographics
NPI:1770257453
Name:TUSSEY, MACKENZIE LEE
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:LEE
Last Name:TUSSEY
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 1:19340 US 68
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45118-8924
Mailing Address - Country:US
Mailing Address - Phone:513-967-2531
Mailing Address - Fax:
Practice Address - Street 1:9193 HAMER RD
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:OH
Practice Address - Zip Code:45121-9472
Practice Address - Country:US
Practice Address - Phone:378-937-6131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOND.20211771235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist