Healthcare Provider Details

I. General information

NPI: 1245711159
Provider Name (Legal Business Name): ELIZABETH MIKELL MCKINNEY MA, CCC/SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2018
Last Update Date: 08/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7370 CABOT CT
MELBOURNE FL
32940-8263
US

IV. Provider business mailing address

6445 GENOA TRL
MELBOURNE FL
32940-7400
US

V. Phone/Fax

Practice location:
  • Phone: 321-622-8792
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA10216
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: