Provider Demographics
NPI:1477053999
Name:MCKANNA, KASEY LYNN (PT)
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:LYNN
Last Name:MCKANNA
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 1:20964 IVY CIR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-2224
Mailing Address - Country:US
Mailing Address - Phone:419-303-2342
Mailing Address - Fax:
Practice Address - Street 1:23715 LITTLE MACK AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1181
Practice Address - Country:US
Practice Address - Phone:586-447-4070
Practice Address - Fax:586-447-4069
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015867225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist