Provider Demographics
NPI:1922682616
Name:MCKENNA, ABIGAIL ROSE
Entity Type:Individual
Prefix:MISS
First Name:ABIGAIL
Middle Name:ROSE
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:ABIGAIL
Other - Middle Name:ROSE
Other - Last Name:MCKENNA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5039 VILLA LINDE PKWY STE 30
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3450
Mailing Address - Country:US
Mailing Address - Phone:989-401-2244
Mailing Address - Fax:
Practice Address - Street 1:3245 KEEWAHDIN RD
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3498
Practice Address - Country:US
Practice Address - Phone:810-937-2345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-08
Last Update Date:2021-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician