MEDICARE: VIRGINIA MCKENNA M.ED.

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	101YP2500X	Professional Counselor	LPC 005350	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LPC 005350	OTHER	GA	STATE OF GEORGIA

General Provider Information

NPI Number	:	1881801181
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIRGINIA MCKENNA M.ED.

Provider Business Mailing Address
First Line	:	1551 JENNINGS MILL RD
Second Line	:	RESOURCE VALLEY, SUITE 1700-B
City	:	BOGART
State	:	GA
Zip	:	30622-2544
Country	:	US
Telephone Number	:	706-338-3688
Fax Number	:

Provider Business Practice Location Address
First Line	:	1551 JENNINGS MILL RD
Second Line	:	RESOURCE VALLEY, SUITE 1700-B
City	:	BOGART
State	:	GA
Zip	:	30622-2544
Country	:	US
Telephone Number	:	706-338-3688
Fax Number	:

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

Provider Enumeration Date	:	05/17/2007
Last Update Date	:	12/29/2008

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