Healthcare Provider Details

I. General information

NPI: 1558055459
Provider Name (Legal Business Name): MACKENZIE LYNN BUGG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 13TH ST
PRAIRIE DU SAC WI
53578-1252
US

IV. Provider business mailing address

188 MARIAHWYNN TER
LODI WI
53555-8802
US

V. Phone/Fax

Practice location:
  • Phone: 608-643-5990
  • Fax:
Mailing address:
  • Phone: 815-651-5369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number6639-154
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: