Basic Information
| Provider Information | |||||||||
| NPI: | 1508232133 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCKINNISS | ||||||||
| FirstName: | HAROLD | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 S EDWIN C MOSES BLVD | ||||||||
| Address2: | SAMARITAN BEHAVIRORAL HEALTH, 4TH FLOOR, NW BLDG | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454173424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377348333 | ||||||||
| FaxNumber: | 9372768269 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 S EDWIN C MOSES BLVD | ||||||||
| Address2: | SAMARITAN BEHAVIRORAL HEALTH, 4TH FLOOR, NW BLDG | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454173424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377348333 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2015 | ||||||||
| LastUpdateDate: | 08/18/2015 | ||||||||
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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 | 167G00000X | PN128169MEDS | OH | Y | Nursing Service Providers | Licensed Psychiatric Technician |
No ID Information.