Provider Demographics
NPI:1063299303
Name:COLLENTINE, MACKENZIE ROSAMOND (MS CF-SLP)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:ROSAMOND
Last Name:COLLENTINE
Suffix:
Gender:F
Credentials:MS CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:568 BLUE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3604
Mailing Address - Country:US
Mailing Address - Phone:706-364-5262
Mailing Address - Fax:
Practice Address - Street 1:568 BLUE RIDGE DR
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3604
Practice Address - Country:US
Practice Address - Phone:706-364-5262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET003930235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist