Provider Demographics
NPI:1740017763
Name:MULLOCK, MCKENNA
Entity type:Individual
Prefix:
First Name:MCKENNA
Middle Name:
Last Name:MULLOCK
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 1:505 12TH ST S APT 205
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-2505
Mailing Address - Country:US
Mailing Address - Phone:920-213-9486
Mailing Address - Fax:
Practice Address - Street 1:151 8TH ST S # 115
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-4423
Practice Address - Country:US
Practice Address - Phone:320-308-0121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-14
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician