Provider Demographics
NPI:1730743899
Name:PETTIT, MAKENZIE
Entity type:Individual
Prefix:
First Name:MAKENZIE
Middle Name:
Last Name:PETTIT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 GOLDENROD RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-7276
Mailing Address - Country:US
Mailing Address - Phone:309-573-5394
Mailing Address - Fax:309-324-7003
Practice Address - Street 1:304 GOLDENROD RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-7276
Practice Address - Country:US
Practice Address - Phone:309-573-5394
Practice Address - Fax:309-324-7003
Is Sole Proprietor?:No
Enumeration Date:2019-04-24
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist