Provider Demographics
NPI:1326575960
Name:COSOTTILE, MCKENNA N (PHD)
Entity Type:Individual
Prefix:
First Name:MCKENNA
Middle Name:N
Last Name:COSOTTILE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MCKENNA
Other - Middle Name:
Other - Last Name:CORLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:4744 41ST AVE SW STE 101
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98116-4566
Practice Address - Country:US
Practice Address - Phone:206-320-5780
Practice Address - Fax:206-320-5794
Is Sole Proprietor?:No
Enumeration Date:2017-05-14
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY61150885103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical