Provider Demographics
NPI:1972804151
Name:MCINNIS, JOHN DENNARD (LCSW)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DENNARD
Last Name:MCINNIS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:DENNARD
Other - Middle Name:
Other - Last Name:MCINNIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:14416 AMERICAN KESTREL DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78738-6520
Mailing Address - Country:US
Mailing Address - Phone:512-318-5929
Mailing Address - Fax:
Practice Address - Street 1:14416 AMERICAN KESTREL DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78738-6520
Practice Address - Country:US
Practice Address - Phone:512-318-5929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-04
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX54105104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX330335601Medicaid