Provider Demographics
NPI:1508044488
Name:MCINNIS, JOHN THOMAS (LADC LEVEL I)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:THOMAS
Last Name:MCINNIS
Suffix:
Gender:M
Credentials:LADC LEVEL I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 WOLF HILL
Mailing Address - Street 2:PO BOX 500
Mailing Address - City:E SANDWICH
Mailing Address - State:MA
Mailing Address - Zip Code:02537
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36 WOLF HILL
Practice Address - Street 2:
Practice Address - City:E SANDWICH
Practice Address - State:MA
Practice Address - Zip Code:02537
Practice Address - Country:US
Practice Address - Phone:508-888-1279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-04
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1126101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)