Provider Demographics
NPI:1386369189
Name:MCKENNA, DEVON WILLIAM (PTA)
Entity type:Individual
Prefix:
First Name:DEVON
Middle Name:WILLIAM
Last Name:MCKENNA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:981 US HIGHWAY 22 FL 2
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:08807-2946
Mailing Address - Country:US
Mailing Address - Phone:201-801-7141
Mailing Address - Fax:
Practice Address - Street 1:622 EAGLE ROCK AVE
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-2994
Practice Address - Country:US
Practice Address - Phone:973-669-0078
Practice Address - Fax:973-669-1113
Is Sole Proprietor?:No
Enumeration Date:2022-10-05
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00397200225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant