Healthcare Provider Details

I. General information

NPI: 1801559661
Provider Name (Legal Business Name): JUSTIN EDWARD MCKINNEY MS, NCC, LCHMCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2021
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 SHIPYARD BLVD
WILMINGTON NC
28412-6431
US

IV. Provider business mailing address

615 SHIPYARD BLVD
WILMINGTON NC
28412-6431
US

V. Phone/Fax

Practice location:
  • Phone: 910-343-0145
  • Fax:
Mailing address:
  • Phone: 910-343-0145
  • Fax: 910-202-9966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA17061
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberA17061
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: