MEDICARE: DR. ELISABETH RUTH MCKENNA PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PSY 16746	CA

General Provider Information

NPI Number	:	1518012962
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELISABETH RUTH MCKENNA PH.D.

Provider Business Mailing Address
First Line	:	PO BOX 152
Second Line	:
City	:	LOS ALTOS
State	:	CA
Zip	:	94023-0152
Country	:	US
Telephone Number	:	408-497-9977
Fax Number	:

Provider Business Practice Location Address
First Line	:	2100 WALSH AVE
Second Line	:	SUITE C1
City	:	SANTA CLARA
State	:	CA
Zip	:	95050-2545
Country	:	US
Telephone Number	:	408-497-9977
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2007
Last Update Date	:	08/08/2013

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