Provider Demographics
NPI:1356638654
Name:MCKENNA, COLLEEN (LSW)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3455 ROUTE 66
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07753-2758
Mailing Address - Country:US
Mailing Address - Phone:732-292-2929
Mailing Address - Fax:732-782-0345
Practice Address - Street 1:3455 ROUTE 66
Practice Address - Street 2:
Practice Address - City:NEPTUNE
Practice Address - State:NJ
Practice Address - Zip Code:07753-2758
Practice Address - Country:US
Practice Address - Phone:732-292-2929
Practice Address - Fax:732-782-0345
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC055906001041C0700X
NJ37LC00218500101YA0400X
NJ44SL05622100101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4542703Medicaid