Provider Demographics
NPI:1174853386
Name:MACMILLAN, CARMEN MARIE (LPC)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:MARIE
Last Name:MACMILLAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 CLUB RD STE 160
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-2439
Mailing Address - Country:US
Mailing Address - Phone:541-345-1722
Mailing Address - Fax:541-485-7049
Practice Address - Street 1:66 CLUB RD STE 120
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2439
Practice Address - Country:US
Practice Address - Phone:541-393-5983
Practice Address - Fax:541-393-5984
Is Sole Proprietor?:No
Enumeration Date:2010-01-11
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORC5822101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
15091907OtherCAQH ID
OR500661183Medicaid