MEDICARE: JOAN L. MCKENNA LCSW

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	1041C0700X	Clinical Social Worker	LCS21577	CA

General Provider Information

NPI Number	:	1669540944
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOAN L. MCKENNA LCSW

Provider Business Mailing Address
First Line	:	429 CAMPANA PL
Second Line	:
City	:	ARROYO GRANDE
State	:	CA
Zip	:	93420-2322
Country	:	US
Telephone Number	:	805-801-0536
Fax Number	:

Provider Business Practice Location Address
First Line	:	708 E GRAND AVE
Second Line	:
City	:	ARROYO GRANDE
State	:	CA
Zip	:	93420-3244
Country	:	US
Telephone Number	:	805-801-0536
Fax Number	:

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

Provider Enumeration Date	:	12/02/2006
Last Update Date	:	07/08/2007

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