Healthcare Provider Details

I. General information

NPI: 1427771963
Provider Name (Legal Business Name): MACKENZIE WILLIAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2022
Last Update Date: 09/20/2022
Certification Date: 09/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19600 E ROSS ST
TAHLEQUAH OK
74464-0545
US

IV. Provider business mailing address

1412 STERLING ST
FORT GIBSON OK
74434-8252
US

V. Phone/Fax

Practice location:
  • Phone: 539-234-1100
  • Fax:
Mailing address:
  • Phone: 918-348-4422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number5721
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: