Provider Demographics
NPI:1891948469
Name:MCKENZIE, ALICIA (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1013 ENON CT
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-0431
Mailing Address - Country:US
Mailing Address - Phone:904-940-4795
Mailing Address - Fax:
Practice Address - Street 1:1013 ENON CT
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-0431
Practice Address - Country:US
Practice Address - Phone:904-940-4795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-28
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 9049235Z00000X
376J00000X, 372600000X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No376J00000XNursing Service Related ProvidersHomemaker
No372600000XNursing Service Related ProvidersAdult Companion
No252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000828900Medicaid
FL001689700Medicaid