Healthcare Provider Details

I. General information

NPI: 1316857881
Provider Name (Legal Business Name): MCKENNA CARMEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 CHATHAM RD STE 4732
SPRINGFIELD IL
62704-4188
US

IV. Provider business mailing address

2501 CHATHAM RD STE 4732
SPRINGFIELD IL
62704-4188
US

V. Phone/Fax

Practice location:
  • Phone: 312-379-9309
  • Fax:
Mailing address:
  • Phone: 312-379-9309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: