Provider Demographics
NPI:1346307915
Name:MCKENNA, KENNETH ALLEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ALLEN
Last Name:MCKENNA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2606 BRANDI LN
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:TX
Mailing Address - Zip Code:76210-1625
Mailing Address - Country:US
Mailing Address - Phone:940-595-9152
Mailing Address - Fax:940-497-9153
Practice Address - Street 1:1406 N CORINTH ST
Practice Address - Street 2:SUITE 405
Practice Address - City:CORINTH
Practice Address - State:TX
Practice Address - Zip Code:76208-5448
Practice Address - Country:US
Practice Address - Phone:940-595-0152
Practice Address - Fax:940-497-9153
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30747103TC0700X, 103TC1900X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3-0747OtherLICENSE #
TX3-0747OtherLICENSE #
TX00844EMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
TX86931AMedicare UPIN