Provider Demographics
NPI:1104390939
Name:MACKINNON, MIKAYLA
Entity Type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:
Last Name:MACKINNON
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 1:197 QUINCY AVE STE 111
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-2359
Mailing Address - Country:US
Mailing Address - Phone:774-480-4656
Mailing Address - Fax:781-356-0894
Practice Address - Street 1:197 QUINCY AVE STE 111
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-2359
Practice Address - Country:US
Practice Address - Phone:774-480-4656
Practice Address - Fax:781-356-0894
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health