Provider Demographics
NPI:1043025695
Name:MCKINZIE, CONNER JOHN
Entity type:Individual
Prefix:
First Name:CONNER
Middle Name:JOHN
Last Name:MCKINZIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 HIMROD ST APT 2R
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11237-4616
Mailing Address - Country:US
Mailing Address - Phone:214-926-2284
Mailing Address - Fax:
Practice Address - Street 1:107 W 82ND ST # LLP101
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-5511
Practice Address - Country:US
Practice Address - Phone:646-389-4112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-11
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP127394101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health