Provider Demographics
NPI:1043427412
Name:MCKENNA, MATTHEW PATRICK (OT)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:PATRICK
Last Name:MCKENNA
Suffix:
Gender:M
Credentials:OT
Other - Prefix:MR
Other - First Name:MATTHEW
Other - Middle Name:PATRICK
Other - Last Name:MCKENNA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OT
Mailing Address - Street 1:62 LEWIS RD
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478
Mailing Address - Country:US
Mailing Address - Phone:617-484-8921
Mailing Address - Fax:
Practice Address - Street 1:62 LEWIS RD
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MA
Practice Address - Zip Code:02478
Practice Address - Country:US
Practice Address - Phone:617-484-8921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8949225CA2400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225CA2400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorAssistive Technology Practitioner