Basic Information
| Provider Information | |||||||||
| NPI: | 1568084846 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIST | ||||||||
| FirstName: | MCKENZIE | ||||||||
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| Credential: | MHS, CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6450 BLACK RIDGE VW APT 202 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809244455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797478841 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6190 BARNES RD | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809222600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192471511 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2020 | ||||||||
| LastUpdateDate: | 05/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | PSLP.0000520 | CO | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.