Healthcare Provider Details

I. General information

NPI: 1194151035
Provider Name (Legal Business Name): EDWARD MCKIE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2013
Last Update Date: 09/01/2023
Certification Date: 09/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4045 E UNION HILLS DR STE A109
PHOENIX AZ
85050-3386
US

IV. Provider business mailing address

4045 E UNION HILLS DR STE A109
PHOENIX AZ
85050-3386
US

V. Phone/Fax

Practice location:
  • Phone: 602-675-2177
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: