Provider Demographics
NPI:1093738221
Name:MACMILLEN, JOHN WALTON JR (LCSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WALTON
Last Name:MACMILLEN
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:WALTON
Other - Last Name:MACMILLEN
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:CLINICAL SOCIAL WORK
Mailing Address - Street 1:186 BEAGLE RD
Mailing Address - Street 2:
Mailing Address - City:MILL HALL
Mailing Address - State:PA
Mailing Address - Zip Code:17751-9492
Mailing Address - Country:US
Mailing Address - Phone:570-726-3904
Mailing Address - Fax:570-726-9919
Practice Address - Street 1:186 BEAGLE RD
Practice Address - Street 2:
Practice Address - City:MILL HALL
Practice Address - State:PA
Practice Address - Zip Code:17751-9492
Practice Address - Country:US
Practice Address - Phone:570-726-3904
Practice Address - Fax:570-726-9919
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0153151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical