Provider Demographics
NPI:1235808460
Name:MCKINNEY, MARESA (LPC)
Entity Type:Individual
Prefix:
First Name:MARESA
Middle Name:
Last Name:MCKINNEY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 1ST ST SE
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31768-5910
Mailing Address - Country:US
Mailing Address - Phone:229-891-6223
Mailing Address - Fax:
Practice Address - Street 1:719 1ST ST SE
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-5509
Practice Address - Country:US
Practice Address - Phone:229-891-6223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-10
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC003755101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional