Provider Demographics
NPI:1316943095
Name:MCKENNA, SUZANNE (PHD)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 N 34TH ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-0352
Mailing Address - Country:US
Mailing Address - Phone:479-202-9956
Mailing Address - Fax:479-202-9956
Practice Address - Street 1:211 N 34TH ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-0352
Practice Address - Country:US
Practice Address - Phone:479-202-9956
Practice Address - Fax:479-202-9956
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2016-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR10-07P103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5G726Medicare PIN
MO000015680OtherMEDICARE GROUP PTAN
MO222865680Medicare PIN