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General NPI Number Information
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NPI Number | 1144377359
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Entity Type | Individual
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Provider Name | DAVE THOMAS MCKENNA M.A.
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Gender | Male
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Dates
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Enumeration Date | 01/03/2007
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Last Update Date | 02/09/2015
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Provider Practice Location Address
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Address Line | 2592 E GRAND AVE SUITE 202
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City | LINDENHURST
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State | IL
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Zip | 60046-5915
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Country | US
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Telephone | 847-651-4719
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Fax |
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Provider Business Mailing Address
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Address Line | 1610 ORIOLE CT
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City | LINDENHURST
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State | IL
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Zip | 60046-9509
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Country | US
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Telephone | 847-651-4719
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 180005667
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License Number State | IL
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