Provider Demographics
NPI:1811295173
Name:MCKINNEY, CORMACK H (PSYD)
Entity type:Individual
Prefix:
First Name:CORMACK
Middle Name:H
Last Name:MCKINNEY
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 1:9650 ZELZAH AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-2003
Mailing Address - Country:US
Mailing Address - Phone:818-830-0200
Mailing Address - Fax:818-830-0206
Practice Address - Street 1:9650 ZELZAH AVE
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-2003
Practice Address - Country:US
Practice Address - Phone:818-830-0200
Practice Address - Fax:818-830-0206
Is Sole Proprietor?:No
Enumeration Date:2011-03-09
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPS2012449103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical