Basic Information
| Provider Information | |||||||||
| NPI: | 1386369189 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKENNA | ||||||||
| FirstName: | DEVON | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 981 US HIGHWAY 22 FL 2 | ||||||||
| Address2: | |||||||||
| City: | BRIDGEWATER | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088072946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018017141 | ||||||||
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| Practice Location | |||||||||
| Address1: | 622 EAGLE ROCK AVE | ||||||||
| Address2: | |||||||||
| City: | WEST ORANGE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070522994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9736690078 | ||||||||
| FaxNumber: | 9736691113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2022 | ||||||||
| LastUpdateDate: | 10/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 40QB00397200 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.