Provider Demographics
NPI:1134673650
Name:MCKENNA, MARY ELLEN (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 CUSHING LN
Mailing Address - Street 2:
Mailing Address - City:LUNENBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01462-1413
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26 CUSHING LN
Practice Address - Street 2:
Practice Address - City:LUNENBURG
Practice Address - State:MA
Practice Address - Zip Code:01462-1413
Practice Address - Country:US
Practice Address - Phone:978-582-9541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-12
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3153225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist