Provider Demographics
NPI:1396158796
Name:DETERMAN, MACKENZIE (MS, SLP-CF)
Entity type:Individual
Prefix:MS
First Name:MACKENZIE
Middle Name:
Last Name:DETERMAN
Suffix:
Gender:F
Credentials:MS, SLP-CF
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:
Other - Last Name:SCHORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:309 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56278-1357
Mailing Address - Country:US
Mailing Address - Phone:320-839-4271
Mailing Address - Fax:320-839-4196
Practice Address - Street 1:15620 EDGEWOOD DR
Practice Address - Street 2:STE 240
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56401-6983
Practice Address - Country:US
Practice Address - Phone:218-454-7012
Practice Address - Fax:218-454-7015
Is Sole Proprietor?:No
Enumeration Date:2014-06-04
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9284235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist