Provider Demographics
NPI:1902476435
Name:GOODREAU, MACKENZIE M (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:M
Last Name:GOODREAU
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 E OLIN AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-1467
Mailing Address - Country:US
Mailing Address - Phone:608-252-1320
Mailing Address - Fax:608-252-1333
Practice Address - Street 1:128 E OLIN AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53713-1467
Practice Address - Country:US
Practice Address - Phone:608-252-1320
Practice Address - Fax:608-252-1333
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5234235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5234-154OtherWI DEPARTMENT OF SAFETY & PROFESSIONAL SERVICES