Healthcare Provider Details

I. General information

NPI: 1225756315
Provider Name (Legal Business Name): BRENDAN MACKINNON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2022
Last Update Date: 01/04/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2412 SENECA ST
BUFFALO NY
14210-2662
US

IV. Provider business mailing address

227 THORN AVE
ORCHARD PARK NY
14127-2600
US

V. Phone/Fax

Practice location:
  • Phone: 716-566-6507
  • Fax: 866-242-7286
Mailing address:
  • Phone: 716-662-2040
  • Fax: 716-662-0019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number39174
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: