Provider Demographics
NPI:1164765772
Name:MCKINNEY, RESEALIA MARIE (IMH)
Entity Type:Individual
Prefix:MRS
First Name:RESEALIA
Middle Name:MARIE
Last Name:MCKINNEY
Suffix:
Gender:F
Credentials:IMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8069 DRESSAGE DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32818-8235
Mailing Address - Country:US
Mailing Address - Phone:407-319-3207
Mailing Address - Fax:
Practice Address - Street 1:8069 DRESSAGE DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32818-8235
Practice Address - Country:US
Practice Address - Phone:407-319-3207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-02
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9173101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health