Provider Demographics
NPI:1104548817
Name:SEAL, MACKENZIE ELAINE
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:ELAINE
Last Name:SEAL
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 1:108 SE CRESTWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7426
Mailing Address - Country:US
Mailing Address - Phone:561-427-8387
Mailing Address - Fax:
Practice Address - Street 1:1607 NW FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-9600
Practice Address - Country:US
Practice Address - Phone:772-291-1614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-19
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA21985235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSA21985OtherSPEECH LANGUAGE PATHOLOGY