Provider Demographics
NPI:1669540944
Name:MCKENNA, JOAN L (LCSW)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:L
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 CAMPANA PL
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-2322
Mailing Address - Country:US
Mailing Address - Phone:805-801-0536
Mailing Address - Fax:
Practice Address - Street 1:708 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-3244
Practice Address - Country:US
Practice Address - Phone:805-801-0536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS215771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALCS21577Medicare ID - Type Unspecified