Provider Demographics
NPI:1053787457
Name:MCMILLAN, MARK (LMSW)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MCMILLAN
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 HILTON RD STE 1
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-2505
Mailing Address - Country:US
Mailing Address - Phone:248-907-0247
Mailing Address - Fax:248-907-0247
Practice Address - Street 1:800 HILTON RD STE 1
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-2505
Practice Address - Country:US
Practice Address - Phone:248-907-0247
Practice Address - Fax:248-907-0247
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010976501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical