Provider Demographics
NPI:1942508387
Name:ANDERSON, MCKENNA LISE (MPT)
Entity Type:Individual
Prefix:
First Name:MCKENNA
Middle Name:LISE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4908 VALLEY RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-1029
Mailing Address - Country:US
Mailing Address - Phone:323-294-7671
Mailing Address - Fax:
Practice Address - Street 1:6133 BRISTOL PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-6609
Practice Address - Country:US
Practice Address - Phone:310-337-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-09
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 37625225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist