Healthcare Provider Details

I. General information

NPI: 1548819246
Provider Name (Legal Business Name): KIANTE MCKINLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2019
Last Update Date: 04/01/2022
Certification Date: 04/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

172 GOLDENROD AVE
PERRIS CA
92570-7239
US

IV. Provider business mailing address

10425 PAINTER AVE
SANTA FE SPRINGS CA
90670-3429
US

V. Phone/Fax

Practice location:
  • Phone: 310-926-6495
  • Fax:
Mailing address:
  • Phone: 562-906-2685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number105308
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: