Provider Demographics
NPI:1619153673
Name:MCKENNA, CAROL A (PHD)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:140 WOOD RD STE 305
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-2514
Mailing Address - Country:US
Mailing Address - Phone:617-407-4705
Mailing Address - Fax:617-607-7567
Practice Address - Street 1:140 WOOD RD
Practice Address - Street 2:STE 101
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-2512
Practice Address - Country:US
Practice Address - Phone:617-407-4705
Practice Address - Fax:617-607-7567
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-21
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7479103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA828377534OtherOPTUM
MA8329-01OtherHARVARD PILGRIM HEALTH
MA21482OtherBEACON HEALTH
MAV22582OtherNETWORK HEALTH
MA110093018AMedicaid
MAW05840OtherBLUE CROSS BLUE SHEILD OF MASS
MA138881OtherVALUE OPTIONS
MAW50421Medicare PIN