Provider Demographics
NPI:1275812372
Name:MACKINNON, CRYSTAL (LCSW)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:MACKINNON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 LONG HILL RD STE 201
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-3811
Mailing Address - Country:US
Mailing Address - Phone:860-333-8765
Mailing Address - Fax:833-204-4896
Practice Address - Street 1:428 LONG HILL RD STE 201
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-3811
Practice Address - Country:US
Practice Address - Phone:860-333-8765
Practice Address - Fax:833-204-4896
Is Sole Proprietor?:No
Enumeration Date:2011-08-08
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0087091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT040400564Medicaid