Provider Demographics
NPI:1942635149
Name:MCINNIS, KENNETH BRYAN (LPC)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:BRYAN
Last Name:MCINNIS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 871431
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99687-1431
Mailing Address - Country:US
Mailing Address - Phone:907-917-5900
Mailing Address - Fax:907-917-5902
Practice Address - Street 1:851 E WESTPOINT DR STE 302
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654
Practice Address - Country:US
Practice Address - Phone:907-917-5900
Practice Address - Fax:907-917-5902
Is Sole Proprietor?:No
Enumeration Date:2013-09-06
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKPCOP808101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health