Provider Demographics
NPI:1528834389
Name:WITTROCK, MACKENZIE MARIE (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MACKENZIE
Middle Name:MARIE
Last Name:WITTROCK
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:MARIE
Other - Last Name:STORK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CF-SLP
Mailing Address - Street 1:1831 QUINT AVE
Mailing Address - Street 2:
Mailing Address - City:CARROLL
Mailing Address - State:IA
Mailing Address - Zip Code:51401-3566
Mailing Address - Country:US
Mailing Address - Phone:712-210-4302
Mailing Address - Fax:
Practice Address - Street 1:408 W 8TH ST
Practice Address - Street 2:
Practice Address - City:CARROLL
Practice Address - State:IA
Practice Address - Zip Code:51401-2325
Practice Address - Country:US
Practice Address - Phone:712-210-4302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-01
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA081047235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist