Provider Demographics
NPI:1083909790
Name:MCKINNON, MISHONDA ETHEL
Entity Type:Individual
Prefix:MS
First Name:MISHONDA
Middle Name:ETHEL
Last Name:MCKINNON
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 1:7049 GOLDEN LEAF LN
Mailing Address - Street 2:
Mailing Address - City:HOPE MILLS
Mailing Address - State:NC
Mailing Address - Zip Code:28348-7995
Mailing Address - Country:US
Mailing Address - Phone:910-257-5402
Mailing Address - Fax:
Practice Address - Street 1:2708 NE 14TH ST
Practice Address - Street 2:SUITE 5
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33062-3565
Practice Address - Country:US
Practice Address - Phone:888-880-9270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-10
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC222Q00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist