Provider Demographics
NPI:1578847596
Name:MCKINNEY, LISA W (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:W
Last Name:MCKINNEY
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:H
Other - Last Name:WHITAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:7001 HERITAGE VILLAGE PLZ
Mailing Address - Street 2:SUITE 230
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155-3065
Mailing Address - Country:US
Mailing Address - Phone:904-874-4163
Mailing Address - Fax:
Practice Address - Street 1:5202 BLOSSOM HILL DR
Practice Address - Street 2:
Practice Address - City:HAYMARKET
Practice Address - State:VA
Practice Address - Zip Code:20169-3161
Practice Address - Country:US
Practice Address - Phone:904-874-4163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-10
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT1822106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0717001294OtherVA THERAPY LICENSE