Provider Demographics
NPI:1588329221
Name:MCKENNIE, MIRIAM SIMONE
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:SIMONE
Last Name:MCKENNIE
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 1:2525 HELEN LN
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75181-1857
Mailing Address - Country:US
Mailing Address - Phone:972-882-7190
Mailing Address - Fax:
Practice Address - Street 1:2525 HELEN LN
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75181-1857
Practice Address - Country:US
Practice Address - Phone:972-882-7190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-08
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist