Healthcare Provider Details

I. General information

NPI: 1891453635
Provider Name (Legal Business Name): MACKINLEE SLATE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2021
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3160 NORTHSIDE PKWY NW
ATLANTA GA
30327-1555
US

IV. Provider business mailing address

3160 NORTHSIDE PKWY NW
ATLANTA GA
30327-1598
US

V. Phone/Fax

Practice location:
  • Phone: 404-233-5332
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberPCET003476
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: