Provider Demographics
NPI:1891205605
Name:MCKINNEY, DELOREAN (BEHAVIORAL HEALTH)
Entity Type:Individual
Prefix:MR
First Name:DELOREAN
Middle Name:
Last Name:MCKINNEY
Suffix:
Gender:M
Credentials:BEHAVIORAL HEALTH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4031 W DAYTON ST
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-8377
Mailing Address - Country:US
Mailing Address - Phone:815-344-1230
Mailing Address - Fax:
Practice Address - Street 1:4031 DAYTON AVE
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050
Practice Address - Country:US
Practice Address - Phone:815-344-1230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-06
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9127OtherDSP