Provider Demographics
NPI:1154023562
Name:FORD, MIKENZI (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MIKENZI
Middle Name:
Last Name:FORD
Suffix:
Gender:F
Credentials:MS, 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:PO BOX 567
Mailing Address - Street 2:
Mailing Address - City:MILLVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84326-0567
Mailing Address - Country:US
Mailing Address - Phone:435-820-0055
Mailing Address - Fax:
Practice Address - Street 1:500 E 1400 N
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-8434
Practice Address - Country:US
Practice Address - Phone:435-716-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10836855-4102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist