Provider Demographics
NPI:1184130619
Name:MCKENNA, ROBERT (LMT)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:MCKENNA
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16500 RACE ST
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80602-7640
Mailing Address - Country:US
Mailing Address - Phone:720-840-1385
Mailing Address - Fax:
Practice Address - Street 1:3450 PENROSE PL STE 220
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1810
Practice Address - Country:US
Practice Address - Phone:720-840-1385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-20
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO13299225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist