Provider Demographics
NPI:1114671609
Name:MCKENNA, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
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 1:12 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:BARRINGTON
Mailing Address - State:RI
Mailing Address - Zip Code:02806-2924
Mailing Address - Country:US
Mailing Address - Phone:401-837-2387
Mailing Address - Fax:
Practice Address - Street 1:600 PAWTUCKET AVE
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-6059
Practice Address - Country:US
Practice Address - Phone:401-808-6278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-04
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICDP00772101YA0400X
RIMHC01556101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)