Provider Demographics
NPI:1548775091
Name:MCKINNON, SAMANTHA ROSE (LMHC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ROSE
Last Name:MCKINNON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100A HAVERHILL ST
Mailing Address - Street 2:
Mailing Address - City:METHUEN
Mailing Address - State:MA
Mailing Address - Zip Code:01844-4251
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100A HAVERHILL ST
Practice Address - Street 2:
Practice Address - City:METHUEN
Practice Address - State:MA
Practice Address - Zip Code:01844-4251
Practice Address - Country:US
Practice Address - Phone:978-682-5276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-06
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
MA10728101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1548775091Medicaid