Basic Information
| Provider Information | |||||||||
| NPI: | 1023787066 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCKENNA | ||||||||
| FirstName: | NICOLE | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 CUMMINGS CTR STE 3850 | ||||||||
| Address2: | |||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019156509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9782320332 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 CUMMINGS CENTER | ||||||||
| Address2: | SUITE 3850 | ||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019156509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9782320332 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2021 | ||||||||
| LastUpdateDate: | 09/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 14094 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.