Provider Demographics
NPI:1922598911
Name:CASSIDY, MCKENZIE ELAINE I (MS-CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:ELAINE
Last Name:CASSIDY
Suffix:I
Gender:F
Credentials:MS-CCC-SLP
Other - Prefix:
Other - First Name:MCKENZIE
Other - Middle Name:ELAINE
Other - Last Name:SEXTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS-CCC-SLP
Mailing Address - Street 1:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:411 E CHESTNUT ST # 2
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1713
Practice Address - Country:US
Practice Address - Phone:502-588-0850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-15
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300046593Medicaid
KY7100551330Medicaid