Basic Information
| Provider Information | |||||||||
| NPI: | 1295366383 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NORTHUP | ||||||||
| FirstName: | MACY | ||||||||
| MiddleName: | CHRISTINE | ||||||||
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| Credential: | M.S. CF-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1324 HICKORY LN S | ||||||||
| Address2: | |||||||||
| City: | FORT MEADE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338419373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8635593324 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3020 LAKELAND HIGHLANDS RD | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338034338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636863189 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2020 | ||||||||
| LastUpdateDate: | 01/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SZ9461 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.