Provider Demographics
NPI:1427894179
Name:ANDERSON, MCKENNA MARIE (MS CF-SLP)
Entity type:Individual
Prefix:
First Name:MCKENNA
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MS CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568-9073
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11365 DORSETT RD
Practice Address - Street 2:
Practice Address - City:MARYLAND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63043-3411
Practice Address - Country:US
Practice Address - Phone:314-872-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-02
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024048166235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist