Provider Demographics
NPI:1801205679
Name:MCKENNEY, MICHAEL (MS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MCKENNEY
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 W MAGDALENA LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-7752
Mailing Address - Country:US
Mailing Address - Phone:602-386-7673
Mailing Address - Fax:
Practice Address - Street 1:2210 W MAGDALENA LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-7752
Practice Address - Country:US
Practice Address - Phone:602-386-7673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ00762255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer