Provider Demographics
NPI:1043305691
Name:MCKILLOP, DENNIS JOHN (PHD)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:JOHN
Last Name:MCKILLOP
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:119 BROOKSIDE LANE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1509
Mailing Address - Country:US
Mailing Address - Phone:315-637-5985
Mailing Address - Fax:315-703-2880
Practice Address - Street 1:6834 EAST GENESEE STREET
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066
Practice Address - Country:US
Practice Address - Phone:315-446-3292
Practice Address - Fax:315-703-2880
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY8844103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA7967Medicare PIN