Provider Demographics
NPI:1093939662
Name:MCKINNON, CAROL ANN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:ANN
Last Name:MCKINNON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8835 SW CANYON LN
Mailing Address - Street 2:SUITE 240
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-3443
Mailing Address - Country:US
Mailing Address - Phone:503-292-5439
Mailing Address - Fax:503-292-4738
Practice Address - Street 1:8835 SW CANYON LN
Practice Address - Street 2:SUITE 240
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-3443
Practice Address - Country:US
Practice Address - Phone:503-292-5439
Practice Address - Fax:503-292-4738
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000TLBKDMedicare ID - Type UnspecifiedMEDICARE