Provider Demographics
NPI:1225873177
Name:MACKEN, ELIZABETH ELAINE
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ELAINE
Last Name:MACKEN
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 1:15600 36TH AVE N STE 120
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-3687
Mailing Address - Country:US
Mailing Address - Phone:763-595-0812
Mailing Address - Fax:763-595-0824
Practice Address - Street 1:15600 36TH AVE N STE 120
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55446-3687
Practice Address - Country:US
Practice Address - Phone:763-595-0812
Practice Address - Fax:763-595-0824
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN528896235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist