Provider Demographics
NPI:1811885536
Name:ADOLPH, MCKENNA
Entity type:Individual
Prefix:
First Name:MCKENNA
Middle Name:
Last Name:ADOLPH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 LYNDON FARM CT STE 300
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5005
Mailing Address - Country:US
Mailing Address - Phone:726-202-3039
Mailing Address - Fax:
Practice Address - Street 1:47 PRONGHORN TRL
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-2435
Practice Address - Country:US
Practice Address - Phone:406-585-9044
Practice Address - Fax:406-585-9220
Is Sole Proprietor?:No
Enumeration Date:2025-06-24
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTOTP-OT-LIC-12550225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist