Provider Demographics
NPI:1003126491
Name:MACMILLAN, GRETA E (LCSW)
Entity Type:Individual
Prefix:
First Name:GRETA
Middle Name:E
Last Name:MACMILLAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 NECK RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:CT
Mailing Address - Zip Code:06443-2814
Mailing Address - Country:US
Mailing Address - Phone:860-966-9813
Mailing Address - Fax:
Practice Address - Street 1:149 DURHAM RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-2677
Practice Address - Country:US
Practice Address - Phone:860-966-9813
Practice Address - Fax:203-902-0191
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-19
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0059591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT209589Medicaid
CT209589Medicaid