Provider Demographics
NPI:1437842416
Name:MCKINNON, CLARICE
Entity type:Individual
Prefix:
First Name:CLARICE
Middle Name:
Last Name:MCKINNON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 N QUAKER AVE APT 425B
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79416-2350
Mailing Address - Country:US
Mailing Address - Phone:325-718-8563
Mailing Address - Fax:
Practice Address - Street 1:328 GLEN ST
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-4653
Practice Address - Country:US
Practice Address - Phone:843-934-2697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-26
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
SCRBT-25-412847106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)