Provider Demographics
NPI:1053637215
Name:KINNAMAN, MARK GREGORY (CADC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:GREGORY
Last Name:KINNAMAN
Suffix:
Gender:M
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 E PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-4626
Mailing Address - Country:US
Mailing Address - Phone:712-396-4387
Mailing Address - Fax:712-396-7708
Practice Address - Street 1:933 E PIERCE ST
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-4626
Practice Address - Country:US
Practice Address - Phone:712-396-4387
Practice Address - Fax:712-396-7708
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-13
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)