Provider Demographics
NPI:1730453770
Name:IWEN, MACKENZIE JOHN (MS-CF)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:JOHN
Last Name:IWEN
Suffix:
Gender:M
Credentials:MS-CF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6520 W ENGLISH MEADOWS DR APT I102
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53220-3969
Mailing Address - Country:US
Mailing Address - Phone:414-526-7326
Mailing Address - Fax:
Practice Address - Street 1:3613 S 13TH ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-7253
Practice Address - Country:US
Practice Address - Phone:920-458-4040
Practice Address - Fax:920-208-2982
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-07
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3630-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist