Provider Demographics
NPI:1558959486
Name:NOVAK, MCKENNA LYNN (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:MCKENNA
Middle Name:LYNN
Last Name:NOVAK
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 41ST ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50311-2519
Mailing Address - Country:US
Mailing Address - Phone:515-321-3317
Mailing Address - Fax:
Practice Address - Street 1:13300 HICKMAN RD STE 110
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-8616
Practice Address - Country:US
Practice Address - Phone:515-987-8835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA102120225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist