Healthcare Provider Details

I. General information

NPI: 1629773890
Provider Name (Legal Business Name): TAINESHA NICOLE MCKINNEY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2023
Last Update Date: 04/05/2023
Certification Date: 04/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

554 BLOOMFIELD AVE FL 4
BLOOMFIELD NJ
07003-3307
US

IV. Provider business mailing address

17 DENNIS PL
SUMMIT NJ
07901-1526
US

V. Phone/Fax

Practice location:
  • Phone: 973-771-3300
  • Fax: 973-679-2784
Mailing address:
  • Phone: 347-385-3198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC06015400
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: