Provider Demographics
NPI:1285161554
Name:WOODWORTH, MACKENZIE M (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:M
Last Name:WOODWORTH
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 1:2212 3RD ST W
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-2414
Mailing Address - Country:US
Mailing Address - Phone:701-590-9116
Mailing Address - Fax:
Practice Address - Street 1:141 3RD ST W STE 5
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-5150
Practice Address - Country:US
Practice Address - Phone:701-590-9116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-17
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1565235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist