Provider Demographics
NPI:1508192907
Name:KENNA, IDA ROSE (LPC)
Entity Type:Individual
Prefix:MS
First Name:IDA
Middle Name:ROSE
Last Name:KENNA
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-3818
Mailing Address - Country:US
Mailing Address - Phone:201-339-9200
Mailing Address - Fax:201-339-7842
Practice Address - Street 1:601 BROADWAY
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-3818
Practice Address - Country:US
Practice Address - Phone:201-339-9200
Practice Address - Fax:201-339-7842
Is Sole Proprietor?:No
Enumeration Date:2009-10-20
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00281600101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0021806Medicaid
NJBA526562Medicare PIN