Provider Demographics
NPI:1063422939
Name:MCKAY, THERESA LYNN (LMSW)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:LYNN
Last Name:MCKAY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3771 CONIFER COURT
Mailing Address - Street 2:
Mailing Address - City:BURTCHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48059
Mailing Address - Country:US
Mailing Address - Phone:810-385-3749
Mailing Address - Fax:
Practice Address - Street 1:3111 ELECTRIC AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-8127
Practice Address - Country:US
Practice Address - Phone:810-966-3576
Practice Address - Fax:810-985-7620
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010697771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM97240038Medicare ID - Type Unspecified