Healthcare Provider Details

I. General information

NPI: 1124675293
Provider Name (Legal Business Name): TIMOTHY ROBERT MCKAY LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2019
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 DEMING ST
SOUTH WINDSOR CT
06074-3740
US

IV. Provider business mailing address

152 DEMING ST
SOUTH WINDSOR CT
06074-3740
US

V. Phone/Fax

Practice location:
  • Phone: 860-713-1184
  • Fax: 860-200-2863
Mailing address:
  • Phone: 860-713-1184
  • Fax: 860-200-2863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2392
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: