Provider Demographics
NPI:1508210410
Name:MCKINNEY, CAROLYN
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:MCKINNEY
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 1:64A LONGFELLOW RD
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-1591
Mailing Address - Country:US
Mailing Address - Phone:415-450-8431
Mailing Address - Fax:
Practice Address - Street 1:64A LONGFELLOW RD
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-1591
Practice Address - Country:US
Practice Address - Phone:415-450-8431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-17
Last Update Date:2016-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMO4122271219101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)