Provider Demographics
NPI:1538728290
Name:KELLER, MAKENZIE WRONKOVICH (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MAKENZIE
Middle Name:WRONKOVICH
Last Name:KELLER
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:MAKENZIE
Other - Middle Name:MARIE
Other - Last Name:WRONKOVICH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:308 MARTINSBURG RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-4225
Mailing Address - Country:US
Mailing Address - Phone:740-393-6767
Mailing Address - Fax:937-428-6274
Practice Address - Street 1:308 MARTINSBURG RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-4225
Practice Address - Country:US
Practice Address - Phone:740-393-6767
Practice Address - Fax:937-428-6274
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2204000296235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist