Provider Demographics
NPI:1972163129
Name:MCGINNIS, MAKINNA LEIGH (PSYD)
Entity type:Individual
Prefix:
First Name:MAKINNA
Middle Name:LEIGH
Last Name:MCGINNIS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 E LOCUST ST APT 1
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-2687
Mailing Address - Country:US
Mailing Address - Phone:608-387-2575
Mailing Address - Fax:
Practice Address - Street 1:1220 W VLIET ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53205-2117
Practice Address - Country:US
Practice Address - Phone:414-758-4019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-19
Last Update Date:2024-02-06
Deactivation Date:2022-05-17
Deactivation Code:
Reactivation Date:2022-07-18
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI5165-57103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program