Basic Information
| Provider Information | |||||||||
| NPI: | 1952954596 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKINNEY-FANNING | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCKINNEY | ||||||||
| OtherFirstName: | KRISTIN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1800 COMMUNITY | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647358804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8884031071 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1032 CROSSWINDS CT | ||||||||
| Address2: | |||||||||
| City: | WENTZVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633854836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8884031071 | ||||||||
| FaxNumber: | 6369467925 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2019 | ||||||||
| LastUpdateDate: | 06/25/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 2016040337 | MO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.