Provider Demographics
NPI:1952979510
Name:MCKINNON, GRACE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:MCKINNON
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 1:4203 EASTERN AVENUE
Mailing Address - Street 2:APT 1
Mailing Address - City:MOUNT RAINIER
Mailing Address - State:MD
Mailing Address - Zip Code:20712
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3300 PENNSYLVANIA AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-2408
Practice Address - Country:US
Practice Address - Phone:202-441-7966
Practice Address - Fax:202-441-7966
Is Sole Proprietor?:No
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0000000000Medicaid