Healthcare Provider Details

I. General information

NPI: 1649885997
Provider Name (Legal Business Name): MACKENZIE COULTER CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2020
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16936 FOREST AVE
OAK FOREST IL
60452-4517
US

IV. Provider business mailing address

6020 151ST ST
OAK FOREST IL
60452-1841
US

V. Phone/Fax

Practice location:
  • Phone: 708-342-5318
  • Fax:
Mailing address:
  • Phone: 708-687-0900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSZ9806
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: