Provider Demographics
NPI:1477169001
Name:MACKINTOSH, MCKENNA (DPT)
Entity Type:Individual
Prefix:
First Name:MCKENNA
Middle Name:
Last Name:MACKINTOSH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 S 65TH AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:WA
Mailing Address - Zip Code:98642-3408
Mailing Address - Country:US
Mailing Address - Phone:360-309-6189
Mailing Address - Fax:360-309-6193
Practice Address - Street 1:109 S 65TH AVE STE 105
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:WA
Practice Address - Zip Code:98642-3408
Practice Address - Country:US
Practice Address - Phone:360-309-6189
Practice Address - Fax:360-309-6193
Is Sole Proprietor?:No
Enumeration Date:2020-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT61069123225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPT61069123OtherPHYSICAL THERAPY LICENSE