Provider Demographics
NPI:1699296640
Name:PACK, MCKENZIE
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:
Last Name:PACK
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 1:2407 W LOUISIANA AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79701-5826
Mailing Address - Country:US
Mailing Address - Phone:432-570-4400
Mailing Address - Fax:432-570-4460
Practice Address - Street 1:2407 W LOUISIANA AVE STE 110
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-5826
Practice Address - Country:US
Practice Address - Phone:432-570-4400
Practice Address - Fax:432-570-4460
Is Sole Proprietor?:No
Enumeration Date:2017-06-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX113426OtherTEXAS DEPARTMENT OF LICENSING & REGULATION LICENSED SPEECH PATHOLOGIST INTERN