Provider Demographics
NPI:1689027518
Name:MACINNIS, MIKA LORIEN MORGAN (PHD)
Entity Type:Individual
Prefix:
First Name:MIKA
Middle Name:LORIEN MORGAN
Last Name:MACINNIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 MEMORIAL RD
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-2720
Mailing Address - Country:US
Mailing Address - Phone:401-338-8818
Mailing Address - Fax:
Practice Address - Street 1:291 WATERMAN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-5130
Practice Address - Country:US
Practice Address - Phone:401-338-8818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-15
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS01565103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist