Provider Demographics
NPI:1144377359
Name:MCKENNA, DAVE THOMAS (MA)
Entity Type:Individual
Prefix:
First Name:DAVE
Middle Name:THOMAS
Last Name:MCKENNA
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 ORIOLE CT
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60046-9509
Mailing Address - Country:US
Mailing Address - Phone:847-651-4719
Mailing Address - Fax:
Practice Address - Street 1:2592 E GRAND AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:LINDENHURST
Practice Address - State:IL
Practice Address - Zip Code:60046-5915
Practice Address - Country:US
Practice Address - Phone:847-651-4719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180005667101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional