Basic Information
| Provider Information | |||||||||
| NPI: | 1073604757 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKINNON | ||||||||
| FirstName: | ALLAN | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | LCDP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 165 BENJAMIN ST | ||||||||
| Address2: | |||||||||
| City: | PAWTUCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028613221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017259244 | ||||||||
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| Practice Location | |||||||||
| Address1: | 55 JOHN A CUMMINGS WAY | ||||||||
| Address2: | |||||||||
| City: | WOONSOCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028953247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4012357000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 11/24/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LCDCS00190 | RI | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101Y00000X | PC225 | RI | N | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | AM40912 | 05 | RI | MEDICAID |