Provider Demographics
NPI:1538850193
Name:COOPER, MACKENZIE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 PRESTON AVE APT A
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22903-2159
Mailing Address - Country:US
Mailing Address - Phone:814-384-0083
Mailing Address - Fax:
Practice Address - Street 1:1102 ROSE HILL DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-5128
Practice Address - Country:US
Practice Address - Phone:434-979-8628
Practice Address - Fax:434-979-8536
Is Sole Proprietor?:No
Enumeration Date:2023-05-16
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2204001137235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist