Provider Demographics
NPI:1356818702
Name:MACKINEM, LINDSAY C
Entity Type:Individual
Prefix:
First Name:LINDSAY
Middle Name:C
Last Name:MACKINEM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10308 WILLOW RUN RD APT 1E
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-0118
Mailing Address - Country:US
Mailing Address - Phone:803-360-6873
Mailing Address - Fax:
Practice Address - Street 1:7809 SARDIS RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28270-2757
Practice Address - Country:US
Practice Address - Phone:980-313-5819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-24
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NC23-238221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician