Provider Demographics
NPI:1346063500
Name:KINNELL, DERRYL
Entity type:Individual
Prefix:
First Name:DERRYL
Middle Name:
Last Name:KINNELL
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 1:2300 S MCDONALD ST APT 211
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75069-1587
Mailing Address - Country:US
Mailing Address - Phone:214-945-9095
Mailing Address - Fax:
Practice Address - Street 1:303 S STATE HIGHWAY 78
Practice Address - Street 2:STE 103
Practice Address - City:WYLIE
Practice Address - State:TX
Practice Address - Zip Code:75098
Practice Address - Country:US
Practice Address - Phone:469-342-3468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-06
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX97009101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional