Provider Demographics
NPI:1457987794
Name:MONDEK, MACKENZIE (SCMT, MT-BC)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:MONDEK
Suffix:
Gender:F
Credentials:SCMT, MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2303 S 1800 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-4130
Mailing Address - Country:US
Mailing Address - Phone:630-414-6660
Mailing Address - Fax:
Practice Address - Street 1:2303 S 1800 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-4130
Practice Address - Country:US
Practice Address - Phone:630-414-6660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-18
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT15119225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic TherapistGroup - Single Specialty