Provider Demographics
NPI:1184418659
Name:SKOUMAL, MACKENZIE LEIGH
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:LEIGH
Last Name:SKOUMAL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1726 S COLUMBIAN RD
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:IL
Mailing Address - Zip Code:61061-9211
Mailing Address - Country:US
Mailing Address - Phone:815-217-5466
Mailing Address - Fax:
Practice Address - Street 1:1401 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2315
Practice Address - Country:US
Practice Address - Phone:779-696-4595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-08
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070029010208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation