Provider Demographics
NPI:1972285351
Name:BRADLEY, MACKENZIE BREANNA
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:BREANNA
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:BREANNA
Other - Last Name:BYRD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7282 CROSSWATER STE 100
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-0659
Mailing Address - Country:US
Mailing Address - Phone:903-871-5712
Mailing Address - Fax:903-309-1035
Practice Address - Street 1:7282 CROSSWATER STE 100
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-0659
Practice Address - Country:US
Practice Address - Phone:903-871-5712
Practice Address - Fax:903-309-1035
Is Sole Proprietor?:No
Enumeration Date:2023-08-03
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX121426235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist