Provider Demographics
NPI:1679196687
Name:MCKENNA, MICHAEL JOHN JR (AUD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:MCKENNA
Suffix:JR
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15280 NW 79TH CT STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-5873
Mailing Address - Country:US
Mailing Address - Phone:305-557-3724
Mailing Address - Fax:786-907-4485
Practice Address - Street 1:963 TOWN CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8254
Practice Address - Country:US
Practice Address - Phone:407-774-9880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-26
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2346231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist