Healthcare Provider Details

I. General information

NPI: 1396079125
Provider Name (Legal Business Name): ELIZA CHRISTINE MCKENNA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2009
Last Update Date: 06/04/2022
Certification Date: 05/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2202 ROSEDALE AVE
OAKLAND CA
94601-4326
US

IV. Provider business mailing address

2202 ROSEDALE AVE
OAKLAND CA
94601-4326
US

V. Phone/Fax

Practice location:
  • Phone: 510-495-5440
  • Fax:
Mailing address:
  • Phone: 510-495-5440
  • Fax: 415-775-7730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number25851
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: