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General NPI Number Information
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NPI Number | 1538983283
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Entity Type | Individual
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Provider Name | MAKENZIE LEE MOODY CCC-SLP
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Gender | Female
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Dates
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Enumeration Date | 11/11/2024
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Last Update Date | 11/11/2024
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Provider Practice Location Address
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Address Line | 508 GENTILLY RD
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City | STATESBORO
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State | GA
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Zip | 30458-5149
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Country | US
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Telephone | 912-681-7768
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Fax |
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Provider Business Mailing Address
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Address Line | 226 COURTNEY WAY APT B
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City | STATESBORO
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State | GA
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Zip | 30458-9097
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Country | US
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Telephone | 478-697-1443
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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 | PCET003961
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License Number State | GA
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