Provider Demographics
NPI:1053964494
Name:MCKENNA, GABRIELLE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:GABRIELLE
Other - Middle Name:
Other - Last Name:AUDETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:37 ADAMS ST APT 2
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01604-1669
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 KEYS RD
Practice Address - Street 2:
Practice Address - City:WEST BROOKFIELD
Practice Address - State:MA
Practice Address - Zip Code:01585-6091
Practice Address - Country:US
Practice Address - Phone:401-225-0913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-23
Last Update Date:2024-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MASLP77034235Z00000X
MA77304235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty