Provider Demographics
NPI:1629339767
Name:JOHNSON, MCKINLEY
Entity Type:Individual
Prefix:DR
First Name:MCKINLEY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:KEN
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1700 COMMERCE ST STE 1400
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-5392
Mailing Address - Country:US
Mailing Address - Phone:214-760-9573
Mailing Address - Fax:214-760-9623
Practice Address - Street 1:1700 COMMERCE ST STE 1400
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201-5392
Practice Address - Country:US
Practice Address - Phone:214-760-9573
Practice Address - Fax:214-760-9623
Is Sole Proprietor?:No
Enumeration Date:2012-06-05
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9155101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional