MEDICARE: MACKENZIE KIMMONS M.S., CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	117704	TX

General Provider Information

NPI Number	:	1659095636
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MACKENZIE KIMMONS M.S., CCC-SLP

Provider Business Mailing Address
First Line	:	2614 BRIARBROOK LN
Second Line	:
City	:	GARLAND
State	:	TX
Zip	:	75040-3922
Country	:	US
Telephone Number	:	214-986-7810
Fax Number	:

Provider Business Practice Location Address
First Line	:	3131 MARS DR
Second Line	:
City	:	GARLAND
State	:	TX
Zip	:	75040-3852
Country	:	US
Telephone Number	:	972-675-3030
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2022
Last Update Date	:	10/03/2022

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Directions to “ MACKENZIE KIMMONS M.S., CCC-SLP” Practice Location

Language	Start Address	Practice Location

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