Provider Demographics
NPI:1093565541
Name:MCKINNEY, KIA (LGPC)
Entity Type:Individual
Prefix:
First Name:KIA
Middle Name:
Last Name:MCKINNEY
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 CHESAPEAKE DR STE 1
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21613-9405
Mailing Address - Country:US
Mailing Address - Phone:410-221-2266
Mailing Address - Fax:410-221-2878
Practice Address - Street 1:813 CHESAPEAKE DR STE 1
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613-9405
Practice Address - Country:US
Practice Address - Phone:410-221-2266
Practice Address - Fax:410-221-2878
Is Sole Proprietor?:No
Enumeration Date:2024-03-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP14930101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD479302100Medicaid