Basic Information
| Provider Information | |||||||||
| NPI: | 1518549773 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COULTER | ||||||||
| FirstName: | MACKENZIE | ||||||||
| MiddleName: | ALYSE | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | B.A.A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2172 N BLOCK RD | ||||||||
| Address2: | |||||||||
| City: | REESE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487579347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894158362 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5447 HAMPTON PL | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486049284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9892527044 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2021 | ||||||||
| LastUpdateDate: | 04/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.