Provider Demographics
NPI:1124064191
Name:MCKENNA, NEIL THOMAS (DPT)
Entity type:Individual
Prefix:DR
First Name:NEIL
Middle Name:THOMAS
Last Name:MCKENNA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:674 VIA DE LA VALLE STE 226
Mailing Address - Street 2:
Mailing Address - City:SOLANA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92075-3406
Mailing Address - Country:US
Mailing Address - Phone:858-436-7092
Mailing Address - Fax:858-876-1605
Practice Address - Street 1:674 VIA DE LA VALLE STE 226
Practice Address - Street 2:
Practice Address - City:SOLANA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92075-3406
Practice Address - Country:US
Practice Address - Phone:858-436-7092
Practice Address - Fax:858-876-1605
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT25475225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WPT25475DMedicare ID - Type Unspecified
WPT25475Medicare ID - Type Unspecified
WPT25475CMedicare ID - Type Unspecified
WPT25475BMedicare ID - Type Unspecified