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NPI Code Detail

MEDICARE: KELLY MCKENNA LCSW

MEDICARE: KELLY 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
1101YM0800XMental Health Counselor150010658IL

General Provider Information

NPI Number : 1982723250
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELLY MCKENNA LCSW
Provider Business Mailing Address
First Line : 3400 W NEW LEAF LN
Second Line :
City : PEORIA
State : IL
Zip : 61615-3311
Country : US
Telephone Number : 309-282-1084
Fax Number : 309-282-1089
Provider Business Practice Location Address
First Line : 210 AVENUE C
Second Line :
City : DANVILLE
State : IL
Zip : 61832-5410
Country : US
Telephone Number : 217-442-3200
Fax Number : 217-442-7460
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/28/2007
Last Update Date : 06/08/2009

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Directions to “ KELLY MCKENNA LCSW” Practice Location

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