Provider Demographics
NPI:1508232133
Name:MCKINNISS, HAROLD A
Entity Type:Individual
Prefix:
First Name:HAROLD
Middle Name:A
Last Name:MCKINNISS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S EDWIN C MOSES BLVD
Mailing Address - Street 2:SAMARITAN BEHAVIRORAL HEALTH, 4TH FLOOR, NW BLDG
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-3424
Mailing Address - Country:US
Mailing Address - Phone:937-734-8333
Mailing Address - Fax:937-276-8269
Practice Address - Street 1:601 S EDWIN C MOSES BLVD
Practice Address - Street 2:SAMARITAN BEHAVIRORAL HEALTH, 4TH FLOOR, NW BLDG
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3424
Practice Address - Country:US
Practice Address - Phone:937-734-8333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-18
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN128169MEDS167G00000X
OHRN.518625163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No167G00000XNursing Service ProvidersLicensed Psychiatric Technician