Basic Information
| Provider Information | |||||||||
| NPI: | 1326123605 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKENNA | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KELLEY | ||||||||
| OtherFirstName: | SUSAN | ||||||||
| OtherMiddleName: | R | ||||||||
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| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2170 | ||||||||
| Address2: | |||||||||
| City: | SUMNER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983900480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538402313 | ||||||||
| FaxNumber: | 2538406340 | ||||||||
| Practice Location | |||||||||
| Address1: | 11112 PACIFIC AVE S | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984445749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535371103 | ||||||||
| FaxNumber: | 2535371087 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 02/16/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00008841 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0472MC | 01 | WA | REGENCE BLUE SHIELD | OTHER | 199810 | 01 | WA | DEPT OF LABOR & INDUSTRY | OTHER | 8433211 | 05 | WA | MEDICAID | 8906780 | 01 | WA | CRIME VICTIMS | OTHER |