Provider Demographics
NPI:1750545331
Name:MCKINLEY, MARK (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:MCKINLEY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1745 BROADWAY
Mailing Address - Street 2:17TH FL.
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-4640
Mailing Address - Country:US
Mailing Address - Phone:212-851-8100
Mailing Address - Fax:212-537-0102
Practice Address - Street 1:1745 BROADWAY
Practice Address - Street 2:17TH FL.
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-4640
Practice Address - Country:US
Practice Address - Phone:212-851-8100
Practice Address - Fax:212-537-0102
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-14
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022043103TC0700X
CA26095103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist