Provider Demographics
NPI:1174703631
Name:MCKINLEY, EDWARD M (LICSW)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:M
Last Name:MCKINLEY
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 PARKER ST
Mailing Address - Street 2:
Mailing Address - City:NEWBURYPORT
Mailing Address - State:MA
Mailing Address - Zip Code:01950-4033
Mailing Address - Country:US
Mailing Address - Phone:603-860-4439
Mailing Address - Fax:
Practice Address - Street 1:51 PLEASANT ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:NEWBURYPORT
Practice Address - State:MA
Practice Address - Zip Code:01950-2637
Practice Address - Country:US
Practice Address - Phone:603-860-4439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-13
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH12481041C0700X
MA1139511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA000417901OtherMEDICARE PTAN