Healthcare Provider Details

I. General information

NPI: 1053397646
Provider Name (Legal Business Name): MARY CATHERINE MCKENNA M.A., L.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1316 KNOLLWOOD LN
MENDOTA HEIGHTS MN
55118-1739
US

IV. Provider business mailing address

1316 KNOLLWOOD LN
MENDOTA HEIGHTS MN
55118-1739
US

V. Phone/Fax

Practice location:
  • Phone: 651-552-6762
  • Fax:
Mailing address:
  • Phone: 651-552-6762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP0831
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: