Healthcare Provider Details

I. General information

NPI: 1891844239
Provider Name (Legal Business Name): ODIS MCKINZIE JR. LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 05/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45-329 PUALI ST
KANEOHE HI
96744-2241
US

IV. Provider business mailing address

45-329 PUALI ST
KANEOHE HI
96744-2241
US

V. Phone/Fax

Practice location:
  • Phone: 240-601-5272
  • Fax: 301-682-5326
Mailing address:
  • Phone: 240-601-5272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHC 242
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701003945
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: