Provider Demographics
NPI:1124210182
Name:MCMILLAN, GEORGE WELLINGTON (CTRS)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:WELLINGTON
Last Name:MCMILLAN
Suffix:
Gender:M
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6649 WESTWOOD CT
Mailing Address - Street 2:
Mailing Address - City:W BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-1371
Mailing Address - Country:US
Mailing Address - Phone:248-592-1967
Mailing Address - Fax:
Practice Address - Street 1:30901 PALMER RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48186-9529
Practice Address - Country:US
Practice Address - Phone:734-367-8473
Practice Address - Fax:734-722-9524
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
24390225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1508883299OtherWRPH
24390OtherNATL CNCIL -THER REC CERT