Provider Demographics
NPI:1326123605
Name:MCKENNA, SUSAN R (DPT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:R
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:R
Other - Last Name:KELLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:PO BOX 2170
Mailing Address - Street 2:
Mailing Address - City:SUMNER
Mailing Address - State:WA
Mailing Address - Zip Code:98390-0480
Mailing Address - Country:US
Mailing Address - Phone:253-840-2313
Mailing Address - Fax:253-840-6340
Practice Address - Street 1:11112 PACIFIC AVE S
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98444-5749
Practice Address - Country:US
Practice Address - Phone:253-537-1103
Practice Address - Fax:253-537-1087
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00008841225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0472MCOtherREGENCE BLUE SHIELD
WA199810OtherDEPT OF LABOR & INDUSTRY
WA8433211Medicaid
WA8906780OtherCRIME VICTIMS
WA8855665Medicare ID - Type UnspecifiedPIERCE COUNTY
WA8433211Medicaid