Provider Demographics
NPI:1295058311
Name:SWENSON, MACKENZIE L (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MACKENZIE
Middle Name:L
Last Name:SWENSON
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 1:266 JILL DR
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-5325
Mailing Address - Country:US
Mailing Address - Phone:208-419-3539
Mailing Address - Fax:
Practice Address - Street 1:266 JILL DR
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-5325
Practice Address - Country:US
Practice Address - Phone:208-419-3539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-03
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1949235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist