Provider Demographics
NPI:1518012962
Name:MCKENNA, ELISABETH RUTH (PHD)
Entity type:Individual
Prefix:DR
First Name:ELISABETH
Middle Name:RUTH
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 152
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94023-0152
Mailing Address - Country:US
Mailing Address - Phone:408-497-9977
Mailing Address - Fax:
Practice Address - Street 1:2100 WALSH AVE
Practice Address - Street 2:SUITE C1
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95050-2545
Practice Address - Country:US
Practice Address - Phone:408-497-9977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 16746103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist