Provider Demographics
NPI:1275940744
Name:ROBERTS, MCKENNA FAYE (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MCKENNA
Middle Name:FAYE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9528 CAMELOT DR
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CA
Mailing Address - Zip Code:95492-7973
Mailing Address - Country:US
Mailing Address - Phone:209-603-0908
Mailing Address - Fax:
Practice Address - Street 1:9528 CAMELOT DR
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CA
Practice Address - Zip Code:95492-7973
Practice Address - Country:US
Practice Address - Phone:209-603-0908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19857235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist