Individual
MACKENZIE RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
SLP
Contact information
Practice address
304 NE HOOD AVE, GRESHAM, OR 97030-7450
(503) 666-1333
(503) 666-2444
Mailing address
304 NE HOOD AVE, GRESHAM, OR 97030-7450
(503) 666-1333
(503) 666-2444
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
016695
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
016695
SPEECH AND LANGUAGE PATHOLOGY BOARD
OR
Enumeration date
07/02/2020
Last updated
07/02/2020
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