Provider Demographics
NPI:1558631374
Name:MCKENNA, MARYKATE (MED, MSED, MS)
Entity Type:Individual
Prefix:
First Name:MARYKATE
Middle Name:
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:MED, MSED, MS
Other - Prefix:
Other - First Name:MARYKATE
Other - Middle Name:
Other - Last Name:MATTIACCIO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MED, MSED, MS
Mailing Address - Street 1:7220 W JEFFERSON AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80235-2015
Mailing Address - Country:US
Mailing Address - Phone:877-504-4141
Mailing Address - Fax:
Practice Address - Street 1:7220 W JEFFERSON AVE STE 100
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80235-2015
Practice Address - Country:US
Practice Address - Phone:877-504-4141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-10
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-16-23602103K00000X
NY233533881174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No174400000XOther Service ProvidersSpecialist