Provider Demographics
NPI:1972804151
Name:MCINNIS, JOHN DENNARD (LCSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DENNARD
Last Name:MCINNIS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:DENNARD
Other - Middle Name:
Other - Last Name:MCINNIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:101 FEU FOLLET RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-4234
Mailing Address - Country:US
Mailing Address - Phone:713-686-9194
Mailing Address - Fax:
Practice Address - Street 1:4131 SPICEWOOD SPRINGS RD STE J1
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8600
Practice Address - Country:US
Practice Address - Phone:713-686-9194
Practice Address - Fax:713-686-9413
Is Sole Proprietor?:No
Enumeration Date:2010-11-04
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX541051041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX330335601Medicaid