MEDICARE: KENNETH MCKENNA, PHD LLC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1346307915	OTHER		NPPES

General Provider Information

NPI Number	:	1679117055
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENNETH MCKENNA, PHD LLC

Provider Business Mailing Address
First Line	:	1402 N CORINTH ST STE 112
Second Line	:
City	:	CORINTH
State	:	TX
Zip	:	76208-5445
Country	:	US
Telephone Number	:	940-595-9152
Fax Number	:

Provider Business Practice Location Address
First Line	:	1402 N CORINTH ST STE 112
Second Line	:
City	:	CORINTH
State	:	TX
Zip	:	76208-5445
Country	:	US
Telephone Number	:	940-595-9152
Fax Number	:	940-279-1386

Authorized Official
Title or Position	:	PSYCHOLOGIST
Name	:	DR. KENNETH ALLEN MCKENNA
Credential	:	PH.D.
Telephone Number	:	940-595-9152

Provider Enumeration Date	:	10/29/2019
Last Update Date	:	10/29/2019

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