Provider Demographics
NPI:1124391404
Name:SQUARE ONE
Entity Type:Organization
Organization Name:SQUARE ONE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKINNIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-690-6985
Mailing Address - Street 1:3195 ZINFANDEL DR
Mailing Address - Street 2:BLDG G STE 21
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-6376
Mailing Address - Country:US
Mailing Address - Phone:916-690-6985
Mailing Address - Fax:916-731-5576
Practice Address - Street 1:3195 ZINFANDEL DR
Practice Address - Street 2:BLDG G STE 21
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95670-6376
Practice Address - Country:US
Practice Address - Phone:916-690-6985
Practice Address - Fax:916-731-5576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-16
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty