Provider Demographics
NPI:1023141520
Name:MCKINNEY, LORI KIM
Entity type:Individual
Prefix:MS
First Name:LORI
Middle Name:KIM
Last Name:MCKINNEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2658 PARKLANE
Mailing Address - Street 2:
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307-2054
Mailing Address - Country:US
Mailing Address - Phone:209-537-7456
Mailing Address - Fax:
Practice Address - Street 1:800 SCENIC DR
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-6131
Practice Address - Country:US
Practice Address - Phone:209-567-4752
Practice Address - Fax:209-567-4740
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA01-047150101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered171M00000XOther Service ProvidersCase Manager/Care Coordinator