Basic Information
Provider Information
NPI: 1033556790
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MCKENNA
FirstName: BRUCE
MiddleName: EDWARD
NamePrefix: MR.
NameSuffix:  
Credential: LCSW
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 102 CHESTNUT DR
Address2:  
City: HIGH POINT
State: NC
PostalCode: 272626804
CountryCode: US
TelephoneNumber: 3368865594
FaxNumber:  
Practice Location
Address1: 102 CHESTNUT DR
Address2:  
City: HIGH POINT
State: NC
PostalCode: 272626804
CountryCode: US
TelephoneNumber: 3368865594
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/03/2013
LastUpdateDate: 06/03/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
104100000XC008142NCY Behavioral Health & Social Service ProvidersSocial Worker 

No ID Information.


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