Provider Demographics
NPI:1053397646
Name:MCKENNA, MARY CATHERINE (MA, LP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:CATHERINE
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1316 KNOLLWOOD LN
Mailing Address - Street 2:
Mailing Address - City:MENDOTA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55118-1739
Mailing Address - Country:US
Mailing Address - Phone:651-552-6762
Mailing Address - Fax:
Practice Address - Street 1:1316 KNOLLWOOD LN
Practice Address - Street 2:
Practice Address - City:MENDOTA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55118-1739
Practice Address - Country:US
Practice Address - Phone:651-552-6762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0831103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN336K4MCOtherBLUE CROSS BLUE SHIELD
MN336K5MCOtherBCBS INDIVDUAL #