Provider Demographics
NPI:1740816305
Name:MCKENZIE, KIMBERLY JO (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JO
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 COMMERCE AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-1611
Mailing Address - Country:US
Mailing Address - Phone:304-412-4533
Mailing Address - Fax:303-398-7043
Practice Address - Street 1:1402 COMMERCE AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-1611
Practice Address - Country:US
Practice Address - Phone:304-412-4533
Practice Address - Fax:303-398-7043
Is Sole Proprietor?:No
Enumeration Date:2020-03-16
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-2058235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist