Provider Demographics
NPI:1285691162
Name:MCKENNA, MARLA S (CCC SLP)
Entity type:Individual
Prefix:MS
First Name:MARLA
Middle Name:S
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:536 OLD HOWELL RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615
Mailing Address - Country:US
Mailing Address - Phone:336-682-9007
Mailing Address - Fax:
Practice Address - Street 1:1086 JENKINS BRANCH LN
Practice Address - Street 2:
Practice Address - City:MOUNT ULLA
Practice Address - State:NC
Practice Address - Zip Code:28125-8699
Practice Address - Country:US
Practice Address - Phone:877-991-7837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3641235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7401038Medicaid