Provider Demographics
NPI:1356452288
Name:MCKENNELL, MARY ALICE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ALICE
Last Name:MCKENNELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ALICE
Other - Last Name:MCKENNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:26259 NOTTINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-4164
Mailing Address - Country:US
Mailing Address - Phone:909-825-7084
Mailing Address - Fax:909-422-3186
Practice Address - Street 1:11201 BENTON ST
Practice Address - Street 2:LOMA LINDA VA HEALTHCARE SYSTEM
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92357-1000
Practice Address - Country:US
Practice Address - Phone:909-825-7084
Practice Address - Fax:909-422-3186
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 152541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical