Basic Information
| Provider Information | |||||||||
| NPI: | 1972804151 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCINNIS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | DENNARD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCINNIS | ||||||||
| OtherFirstName: | DENNARD | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 101 FEU FOLLET RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705084234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136869194 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4131 SPICEWOOD SPRINGS RD STE J1 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787598600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136869194 | ||||||||
| FaxNumber: | 7136869413 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2010 | ||||||||
| LastUpdateDate: | 06/17/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 54105 | TX | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | 54105 | TX | N | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 330335601 | 05 | TX | MEDICAID |