Provider Demographics
NPI:1669198594
Name:MCKENNA, ETHAN POLEY
Entity type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:POLEY
Last Name:MCKENNA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 OSPREY DR
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-3335
Mailing Address - Country:US
Mailing Address - Phone:484-794-4037
Mailing Address - Fax:
Practice Address - Street 1:9 OSPREY DR
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-3335
Practice Address - Country:US
Practice Address - Phone:484-794-4037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0893224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant