Provider Demographics
NPI:1396889226
Name:MACKINNON, SELENE M (PSYD)
Entity type:Individual
Prefix:
First Name:SELENE
Middle Name:M
Last Name:MACKINNON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 WHALEN DR
Mailing Address - Street 2:
Mailing Address - City:NORTH ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02760-4521
Mailing Address - Country:US
Mailing Address - Phone:508-695-2941
Mailing Address - Fax:
Practice Address - Street 1:115 MAIN ST STE 1A-C2D
Practice Address - Street 2:
Practice Address - City:NORTH EASTON
Practice Address - State:MA
Practice Address - Zip Code:02356-1468
Practice Address - Country:US
Practice Address - Phone:781-551-0999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS00730103TC0700X
MAPSY11838103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical