Provider Demographics
NPI:1508484833
Name:GARVEY, MCKENNA (LCSW)
Entity Type:Individual
Prefix:
First Name:MCKENNA
Middle Name:
Last Name:GARVEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 N MCCARTHY RD STE P
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-9112
Mailing Address - Country:US
Mailing Address - Phone:920-903-1060
Mailing Address - Fax:920-903-1164
Practice Address - Street 1:119 N MCCARTHY RD STE P
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-9112
Practice Address - Country:US
Practice Address - Phone:920-903-1060
Practice Address - Fax:920-903-1164
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-13
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI131862-1211041C0700X
WI9818-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100101583Medicaid