Provider Demographics
NPI:1528796257
Name:MCKENNEY, MARDI TARBET
Entity type:Individual
Prefix:
First Name:MARDI
Middle Name:TARBET
Last Name:MCKENNEY
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 1:621 CAMILLA LN
Mailing Address - Street 2:
Mailing Address - City:LANTANA
Mailing Address - State:TX
Mailing Address - Zip Code:76226-6457
Mailing Address - Country:US
Mailing Address - Phone:940-300-1189
Mailing Address - Fax:
Practice Address - Street 1:1565 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-3394
Practice Address - Country:US
Practice Address - Phone:972-350-4528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18245235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty