Provider Demographics
NPI:1023395837
Name:MCMILLIN, MARISSA H
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:H
Last Name:MCMILLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 LEFFERTS PL
Mailing Address - Street 2:#4B
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-2834
Mailing Address - Country:US
Mailing Address - Phone:402-547-9816
Mailing Address - Fax:
Practice Address - Street 1:1123 BROADWAY
Practice Address - Street 2:STE. 1115
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-2007
Practice Address - Country:US
Practice Address - Phone:402-547-9816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0912141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical