Provider Demographics
NPI:1780300939
Name:ORVOS, MACKENZIE (MED, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:ORVOS
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5619 BELMONT AVE APT 2108
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-6774
Mailing Address - Country:US
Mailing Address - Phone:980-254-2108
Mailing Address - Fax:
Practice Address - Street 1:7203 BRUTON RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75217-1436
Practice Address - Country:US
Practice Address - Phone:972-892-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-18
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45924932235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX117595OtherSPEECH LANGUAGE PATHOLOGIST LICENSE
14260579OtherCERTIFICATE OF CLINICAL COMPETENCE IN SPEECH-LANGUAGE PATHOLOGY (CCC-SLP)