MEDICARE: MAKENZIE MAYALL

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	242006074	IL

General Provider Information

NPI Number	:	1962014977
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAKENZIE MAYALL

Provider Business Mailing Address
First Line	:	1605 E ASH ST
Second Line	:
City	:	CANTON
State	:	IL
Zip	:	61520-1510
Country	:	US
Telephone Number	:	309-647-6951
Fax Number	:

Provider Business Practice Location Address
First Line	:	1605 E ASH ST
Second Line	:
City	:	CANTON
State	:	IL
Zip	:	61520-1510
Country	:	US
Telephone Number	:	309-647-6951
Fax Number	:

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

Provider Enumeration Date	:	08/20/2020
Last Update Date	:	09/03/2021

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Directions to “ MAKENZIE MAYALL ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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