Provider Demographics
NPI:1538582119
Name:MCKENNA, LISA ELLEN (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ELLEN
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 S ACADIAN THRUWAY
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-5636
Mailing Address - Country:US
Mailing Address - Phone:225-726-5538
Mailing Address - Fax:
Practice Address - Street 1:2888 BRIGHTSIDE DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70820-3509
Practice Address - Country:US
Practice Address - Phone:225-769-8160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-02
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6701235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist