Provider Demographics
NPI:1750809000
Name:MINEHAN, MACKENNA MARIE (LMSW)
Entity type:Individual
Prefix:
First Name:MACKENNA
Middle Name:MARIE
Last Name:MINEHAN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:MACKENNA
Other - Middle Name:
Other - Last Name:RUCCI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:175 W 72ND ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-3203
Mailing Address - Country:US
Mailing Address - Phone:858-531-5673
Mailing Address - Fax:
Practice Address - Street 1:325 W 89TH ST APT 7
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-2166
Practice Address - Country:US
Practice Address - Phone:858-531-5673
Practice Address - Fax:858-531-5673
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-07
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0959931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty