Provider Demographics
NPI:1306368337
Name:TIMMINS, MACKENZIE LEE (SLP)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:LEE
Last Name:TIMMINS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5112 ARNOLD AVE
Mailing Address - Street 2:
Mailing Address - City:MCCLELLAN
Mailing Address - State:CA
Mailing Address - Zip Code:95652-1075
Mailing Address - Country:US
Mailing Address - Phone:916-286-5129
Mailing Address - Fax:
Practice Address - Street 1:5112 ARNOLD AVE
Practice Address - Street 2:
Practice Address - City:MCCLELLAN
Practice Address - State:CA
Practice Address - Zip Code:95652-1075
Practice Address - Country:US
Practice Address - Phone:916-286-5129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-11
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist