Provider Demographics
NPI:1407900459
Name:MCKINNELL, MARY A (LCPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:MCKINNELL
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ANN
Other - Last Name:HEILEMEIER AND DECKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8 HEALTH SERVICES DR STE 4
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-9647
Mailing Address - Country:US
Mailing Address - Phone:815-748-8900
Mailing Address - Fax:815-748-8921
Practice Address - Street 1:8 HEALTH SERVICES DR STE 4
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-9647
Practice Address - Country:US
Practice Address - Phone:815-748-8900
Practice Address - Fax:815-748-8921
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILOTH000Medicare UPIN