MEDICARE: MRS. SUZANNE E MCKENNA PT

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	225100000X	Physical Therapist	5882	CO

General Provider Information

NPI Number	:	1558403774
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUZANNE E MCKENNA PT

Provider Business Mailing Address
First Line	:	2279 JEANETTE WAY
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80915-4700
Country	:	US
Telephone Number	:	719-638-8105
Fax Number	:	719-636-3772

Provider Business Practice Location Address
First Line	:	325 PARKSIDE DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80910-3134
Country	:	US
Telephone Number	:	719-630-8000
Fax Number	:	719-636-3772

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

Provider Enumeration Date	:	02/13/2007
Last Update Date	:	07/08/2007

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