Provider Demographics
NPI:1407486269
Name:BALDWIN, MCKENNA KATHLEEN
Entity Type:Individual
Prefix:
First Name:MCKENNA
Middle Name:KATHLEEN
Last Name:BALDWIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1489 PARTRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-8239
Mailing Address - Country:US
Mailing Address - Phone:408-826-1840
Mailing Address - Fax:
Practice Address - Street 1:1489 PARTRIDGE DR
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-8239
Practice Address - Country:US
Practice Address - Phone:408-826-1840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-21
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
XDP869A76254OtherANTHEM BLUE CROSS