Provider Demographics
NPI:1932668803
Name:HINES, MCKENNA L
Entity Type:Individual
Prefix:
First Name:MCKENNA
Middle Name:L
Last Name:HINES
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 1:1321 MURFREESBORO PIKE STE 702
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37217-2679
Mailing Address - Country:US
Mailing Address - Phone:844-359-7629
Mailing Address - Fax:
Practice Address - Street 1:820 DUKE AVE STE A
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-2684
Practice Address - Country:US
Practice Address - Phone:478-225-3882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-19-86069106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician