Provider Demographics
NPI:1316099575
Name:MCKENNA, THEODORAH EMILLIA (LCSW)
Entity type:Individual
Prefix:
First Name:THEODORAH
Middle Name:EMILLIA
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14307 FOOTHILL BLVD UNIT B8
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-7568
Mailing Address - Country:US
Mailing Address - Phone:818-833-0019
Mailing Address - Fax:
Practice Address - Street 1:201 CENTRE PLAZA DR
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-2142
Practice Address - Country:US
Practice Address - Phone:323-526-6578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 190831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical