Provider Demographics
NPI:1164018164
Name:MCKINNEY, MICHIAELA LEE (LBSW)
Entity Type:Individual
Prefix:
First Name:MICHIAELA
Middle Name:LEE
Last Name:MCKINNEY
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:MICHIAELA
Other - Middle Name:LEE
Other - Last Name:SURBER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4615 11TH AVE W APT 110
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-5272
Mailing Address - Country:US
Mailing Address - Phone:701-578-8544
Mailing Address - Fax:
Practice Address - Street 1:603 MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-5467
Practice Address - Country:US
Practice Address - Phone:701-774-0749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-15
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5882104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker