Basic Information
| Provider Information | |||||||||
| NPI: | 1891205605 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKINNEY | ||||||||
| FirstName: | DELOREAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | BEHAVIORAL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4031 W DAYTON ST | ||||||||
| Address2: | |||||||||
| City: | MCHENRY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600508377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153441230 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4031 DAYTON AVE | ||||||||
| Address2: | |||||||||
| City: | MCHENRY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153441230 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2017 | ||||||||
| LastUpdateDate: | 10/06/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TM1800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Mental Retardation & Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 9127 | 01 | IL | DSP | OTHER |