Provider Demographics
NPI:1447079892
Name:FREDERICK, MCKENNA LEE (OTR/L, OTD)
Entity type:Individual
Prefix:
First Name:MCKENNA
Middle Name:LEE
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:OTR/L, OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 SYLVAN LN
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:KS
Mailing Address - Zip Code:67152-3258
Mailing Address - Country:US
Mailing Address - Phone:620-440-0671
Mailing Address - Fax:
Practice Address - Street 1:609 SYLVAN LN
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:KS
Practice Address - Zip Code:67152-3258
Practice Address - Country:US
Practice Address - Phone:620-440-0671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-03
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS17-04206225X00000X
225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist