Provider Demographics
NPI:1366671000
Name:MCKENNA, LISA DAWN (PT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DAWN
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 S 5TH AVE
Mailing Address - Street 2:PT DEPARTMENT 117G
Mailing Address - City:HINES
Mailing Address - State:IL
Mailing Address - Zip Code:60141-3030
Mailing Address - Country:US
Mailing Address - Phone:708-202-2287
Mailing Address - Fax:708-202-2281
Practice Address - Street 1:5000 S 5TH AVE
Practice Address - Street 2:PT DEPARTMENT 117G
Practice Address - City:HINES
Practice Address - State:IL
Practice Address - Zip Code:60141-3030
Practice Address - Country:US
Practice Address - Phone:708-202-2287
Practice Address - Fax:708-202-2281
Is Sole Proprietor?:No
Enumeration Date:2009-07-02
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012879225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist