Provider Demographics
NPI:1023126356
Name:MCKINNON, ROSEANNE
Entity type:Individual
Prefix:MS
First Name:ROSEANNE
Middle Name:
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 1:200 CORNWALL BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:CT
Mailing Address - Zip Code:06069
Mailing Address - Country:US
Mailing Address - Phone:860-364-0665
Mailing Address - Fax:860-364-0665
Practice Address - Street 1:200 CORNWALL BRIDGE RD
Practice Address - Street 2:
Practice Address - City:SHARON
Practice Address - State:CT
Practice Address - Zip Code:06069
Practice Address - Country:US
Practice Address - Phone:860-364-0665
Practice Address - Fax:860-364-0665
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0036791041C0700X
NYR03161211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7491794OtherVALUE OPTIONS
CT004211827Medicaid
CT140003679CT01OtherANTHEM
NY7491794OtherVALUE OPTIONS