Provider Demographics
NPI:1407161243
Name:MCKENNA, MARTHA (MOT/L)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:MOT/L
Other - Prefix:
Other - First Name:MAGGIE
Other - Middle Name:
Other - Last Name:MCKENNA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OT
Mailing Address - Street 1:46 FEDERAL ST
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2125
Mailing Address - Country:US
Mailing Address - Phone:207-319-1905
Mailing Address - Fax:
Practice Address - Street 1:46 FEDERAL ST
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2125
Practice Address - Country:US
Practice Address - Phone:207-319-1905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT1304225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics