Basic Information
| Provider Information | |||||||||
| NPI: | 1437778602 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KINNEY | ||||||||
| FirstName: | KIRKLIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC, PS, ADCII | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5801 E BOGARD RD | ||||||||
| Address2: | |||||||||
| City: | WASILLA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996544267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9079524687 | ||||||||
| FaxNumber: | 9073523373 | ||||||||
| Practice Location | |||||||||
| Address1: | 5801 E BOGARD RD | ||||||||
| Address2: | |||||||||
| City: | WASILLA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996544267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073523252 | ||||||||
| FaxNumber: | 9073523373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2020 | ||||||||
| LastUpdateDate: | 04/08/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 141946 | AK | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 141946 | 01 | AK | STATE OF ALASKA | OTHER |