Provider Demographics
NPI:1003145624
Name:MARY MCMILLAN LCSW
Entity Type:Organization
Organization Name:MARY MCMILLAN LCSW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMILLAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:630-399-2935
Mailing Address - Street 1:PO BOX 392
Mailing Address - Street 2:
Mailing Address - City:NORTH AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60542-0138
Mailing Address - Country:US
Mailing Address - Phone:630-399-2935
Mailing Address - Fax:815-727-4855
Practice Address - Street 1:143 FIRST ST STE 202
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:IL
Practice Address - Zip Code:60510-3102
Practice Address - Country:US
Practice Address - Phone:630-399-2935
Practice Address - Fax:815-727-4855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-10
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490123011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216546Medicare PIN