Provider Demographics
NPI:1982723250
Name:MCKENNA, KELLY (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
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 1:3400 W NEW LEAF LN
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-3311
Mailing Address - Country:US
Mailing Address - Phone:309-282-1084
Mailing Address - Fax:309-282-1089
Practice Address - Street 1:210 AVENUE C
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-5410
Practice Address - Country:US
Practice Address - Phone:217-442-3200
Practice Address - Fax:217-442-7460
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150010658101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health