Provider Demographics
NPI:1942389853
Name:ANDERSON, MCKENZYE JANE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MCKENZYE
Middle Name:JANE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3830
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86003
Mailing Address - Country:US
Mailing Address - Phone:928-226-1563
Mailing Address - Fax:928-526-0158
Practice Address - Street 1:1805 W. HEAVENLY CT.
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001
Practice Address - Country:US
Practice Address - Phone:928-226-1563
Practice Address - Fax:928-526-0158
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP4251235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ834285OtherAHCCCS #
AZSLP4251OtherAZ DHS LICENSE