Provider Demographics
NPI:1548439987
Name:MCKINNON, COLLEEN MAE (LCSW)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MAE
Last Name:MCKINNON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2064
Mailing Address - Street 2:
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959-1942
Mailing Address - Country:US
Mailing Address - Phone:530-274-1469
Mailing Address - Fax:
Practice Address - Street 1:230 MAIN ST
Practice Address - Street 2:SUITE 2C
Practice Address - City:NEVADA CITY
Practice Address - State:CA
Practice Address - Zip Code:95959-2509
Practice Address - Country:US
Practice Address - Phone:530-274-1469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS119351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ24206ZMedicare PIN