Provider Demographics
NPI:1073604757
Name:MCKINNON, ALLAN B (LCDP)
Entity Type:Individual
Prefix:
First Name:ALLAN
Middle Name:B
Last Name:MCKINNON
Suffix:
Gender:M
Credentials:LCDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 BENJAMIN ST
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02861-3221
Mailing Address - Country:US
Mailing Address - Phone:401-725-9244
Mailing Address - Fax:
Practice Address - Street 1:55 JOHN A CUMMINGS WAY
Practice Address - Street 2:
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-3247
Practice Address - Country:US
Practice Address - Phone:401-235-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILCDCS00190101YA0400X
RIPC225101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIAM40912Medicaid