Provider Demographics
NPI:1053919472
Name:MCKINLEY, JUSTIN TYLER
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:TYLER
Last Name:MCKINLEY
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 1:20318 SW 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-5027
Mailing Address - Country:US
Mailing Address - Phone:954-997-9957
Mailing Address - Fax:
Practice Address - Street 1:850 NW FEDERAL HWY STE 173
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-1019
Practice Address - Country:US
Practice Address - Phone:772-362-9878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-16
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician