Provider Demographics
NPI:1073846978
Name:MCKENNA, SANDY DIANA
Entity Type:Individual
Prefix:MS
First Name:SANDY
Middle Name:DIANA
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 W 19TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-2026
Mailing Address - Country:US
Mailing Address - Phone:949-646-9227
Mailing Address - Fax:
Practice Address - Street 1:420 W 19TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-2026
Practice Address - Country:US
Practice Address - Phone:949-646-9227
Practice Address - Fax:949-646-9191
Is Sole Proprietor?:No
Enumeration Date:2009-09-09
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health