Healthcare Provider Details

I. General information

NPI: 1447533310
Provider Name (Legal Business Name): ANDREW MCKINNON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2011
Last Update Date: 12/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 S BURROWES ST STE 702
STATE COLLEGE PA
16801-3864
US

IV. Provider business mailing address

118 E BLADE DR
PA FURNACE PA
16865-9507
US

V. Phone/Fax

Practice location:
  • Phone: 814-441-8855
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW016597
License Number StatePA

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: