Provider Demographics
NPI:1295953503
Name:MACTOUGH, KELLY MARZANO (MS, CCC-SP)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MARZANO
Last Name:MACTOUGH
Suffix:
Gender:F
Credentials:MS, CCC-SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6588 E MOUNTAIN VIEW PL
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85365-1143
Mailing Address - Country:US
Mailing Address - Phone:928-344-1366
Mailing Address - Fax:
Practice Address - Street 1:6588 E MOUNTAIN VIEW PL
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85365-1143
Practice Address - Country:US
Practice Address - Phone:928-344-1366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist