Provider Demographics
NPI:1043857048
Name:CUNNINGHAM, MCKENZIE
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 HARTFORD ST
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79605-4603
Mailing Address - Country:US
Mailing Address - Phone:325-793-3537
Mailing Address - Fax:
Practice Address - Street 1:4545 HARTFORD ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79605-4602
Practice Address - Country:US
Practice Address - Phone:325-793-3537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112473235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112473Medicaid
TX112473OtherCOMMERCIAL INSURANCE