Provider Demographics
NPI:1326519315
Name:MCKENNA, MOLLY (PTA)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:
Other - Last Name:SCHMITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:30 S NEVADA AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-1802
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3740 CRAGWOOD DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-4912
Practice Address - Country:US
Practice Address - Phone:719-237-8855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0012317225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONOtherNONE