Provider Demographics
NPI:1982384178
Name:GIPSON, MACKENLEA
Entity type:Individual
Prefix:
First Name:MACKENLEA
Middle Name:
Last Name:GIPSON
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 1:480 MASSENGALE RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72830-9145
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:810 DAN ARK CIRCLE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:AR
Practice Address - Zip Code:72833
Practice Address - Country:US
Practice Address - Phone:479-747-3596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-21
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist