Provider Demographics
NPI:1811336233
Name:HORBERG, MECKENZIE
Entity type:Individual
Prefix:
First Name:MECKENZIE
Middle Name:
Last Name:HORBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 S 18TH ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-4391
Mailing Address - Country:US
Mailing Address - Phone:563-340-7301
Mailing Address - Fax:
Practice Address - Street 1:503 S 18TH ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-4303
Practice Address - Country:US
Practice Address - Phone:307-742-3728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-19
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.10780235Z00000X
IL146.011323235Z00000X
WYSP-1273235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYSP-1273OtherWYOMING LICENSE
IL1460011232OtherILLINOIS LICENSE
1215875OtherASHA