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General NPI Number Information
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NPI Number | 1538780739
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Entity Type | Individual
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Provider Name | MACKENZIE LANDIS
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Gender | Female
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Dates
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Enumeration Date | 04/29/2020
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Last Update Date | 04/29/2020
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Provider Practice Location Address
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Address Line | 1321 W 7TH AVE
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City | STILLWATER
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State | OK
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Zip | 74074-4360
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Country | US
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Telephone | 405-372-8200
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Fax |
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Provider Business Mailing Address
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Address Line | 1023 S GRAY ST
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City | STILLWATER
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State | OK
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Zip | 74074-5445
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Country | US
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Telephone | 405-332-6410
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | CF185
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License Number State | OK
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