1396158796 NPI number — MS. MACKENZIE DETERMAN M.S., SLP-CF

Table of content: MS. MACKENZIE DETERMAN M.S., SLP-CF (NPI 1396158796)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396158796 NPI number — MS. MACKENZIE DETERMAN M.S., SLP-CF

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DETERMAN
Provider First Name:
MACKENZIE
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
M.S., SLP-CF
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SCHORN
Provider Other First Name:
MACKENZIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1396158796
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
309 WASHINGTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORTONVILLE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56278-1357
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-839-4271
Provider Business Mailing Address Fax Number:
320-839-4196

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15620 EDGEWOOD DR
Provider Second Line Business Practice Location Address:
STE 240
Provider Business Practice Location Address City Name:
BAXTER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56401-6983
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-454-7012
Provider Business Practice Location Address Fax Number:
218-454-7015
Provider Enumeration Date:
06/04/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  9284 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com