Provider Demographics
NPI:1891324851
Name:MCKINNON, GWENDOLYN Y
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:Y
Last Name:MCKINNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 BALL PARK RD
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENA ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29920-5417
Mailing Address - Country:US
Mailing Address - Phone:980-215-4870
Mailing Address - Fax:
Practice Address - Street 1:1875 N PARIS AVE
Practice Address - Street 2:
Practice Address - City:PORT ROYAL
Practice Address - State:SC
Practice Address - Zip Code:29935-2029
Practice Address - Country:US
Practice Address - Phone:843-379-9600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-02
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health