Healthcare Provider Details

I. General information

NPI: 1548376742
Provider Name (Legal Business Name): DAPHNE LYNN MCKINNON MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 09/04/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 RSI DR UNIT 120
LOGAN UT
84321-2203
US

IV. Provider business mailing address

725 LEGEND DR
LOGAN UT
84321-7721
US

V. Phone/Fax

Practice location:
  • Phone: 916-435-7084
  • Fax:
Mailing address:
  • Phone: 916-512-5447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number20778
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11055197-3501
License Number StateUT

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: