Provider Demographics
NPI:1538983283
Name:MOODY, MAKENZIE LEE (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MAKENZIE
Middle Name:LEE
Last Name:MOODY
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 1:226 COURTNEY WAY APT B
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-9097
Mailing Address - Country:US
Mailing Address - Phone:478-697-1443
Mailing Address - Fax:
Practice Address - Street 1:508 GENTILLY RD
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-5149
Practice Address - Country:US
Practice Address - Phone:912-681-7768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET003961235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist