Provider Demographics
NPI:1972686251
Name:MACKERT, ANGELA ELLEN (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:ELLEN
Last Name:MACKERT
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6911 SHANNON WILLOW RD
Mailing Address - Street 2:SUITE 700
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-1346
Mailing Address - Country:US
Mailing Address - Phone:704-540-3777
Mailing Address - Fax:704-540-1443
Practice Address - Street 1:6911 SHANNON WILLOW RD
Practice Address - Street 2:SUITE 700
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-1346
Practice Address - Country:US
Practice Address - Phone:704-540-3777
Practice Address - Fax:704-540-1443
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5857235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7411823Medicaid